2. Mail Address

3. Street Address if different

4. City

5. State

6. Zip

7. Area Code and Home Phone

8. Area Code and Work Phone/Ext.

9. Area Code and FAX

10. Email

11. Contact us Morning Afternoon Evenings

12. Select the type of policy you would like a quote on Homeowners Renter/Tenants Condo Dwelling Fire

13. Current Residence Status Own Rent Other

14. Do you ever rent your property? If yes, for how many weeks?

15. Is this a primary or secondary home? (choose one) Primary Secondary Rental Property

16. Do you need special coverage for jewerly, fine art, antiques, silverware, furs, computers, or other items? Yes No
a. If yes to #16, please list items and approximate value

17. If insured, list name of company insured with

If a renter, skip to question #20

18. Homeowners or Condo (coverage A on existing policy) Amount of coverage on dwelling: (i.e. $150,000) - $

19. Any other structures on the premises ..rented or not (coverage B on existing policy) Yes No
If yes, value, etc.

20. Personal Property (coverage C on existing policy) Amount of coverage on personal property (i.e. $25,000 - Minimum of $15,000)

21. Loss of Use (coverage D on existing policy)
Amount of coverage?

22. Personal Liability (coverage E on existing policy) $300,000 $500,000 $1,000,000

23. Deductible Amount $250.00 $500.00 $1,000.00 $2,000.00

24. Construction Type Wood Frame Other

25. Approximate year residence was built (i.e. 1977)

26. Type of Heat Oil Gas Electric Other

26a. If oil, where is oil tank located? inside/basement outside/above ground outside/underground

27. Check all that apply

Smoke Detectors
Swimming Pool		If Yes, Diving board? Yes No	Fenced? Yes No
Central Burglar/Fire Alarm
Trampoline
Dogs or Horses		If Yes, name breed
Wood, Coal, Pellet Stove

28. Are you or your spouse over 55 years of age? Yes No

28a. If over 55, do you work over 20 hours a week? Yes No

29. Do any household members smoke? Yes No

30. Any business conducted on premises? Yes No
If yes, please describe

Claims/Loss Information

31. Please describe any claims or losses you've had in the past 3 years.

32. Discount Information
Most insurance companies provide a 10% discount on your homeowners policy if you insure your vehicles and residence with them.
Would you be interested in this discount? Yes No

33. Questions and/or Comments