New Page 1

Assess your Risk

How Much Could You Lose?

Does your insurance policy provide adequate protection for your needs? Consider these questions:

Please note fields marked with an * are mandatory fields.
The estimated time to complete this form is 10 minutes.

Contact Information

Please provide the following contact information:

First Name *

Last Name *

Street Address *

Address (cont.)

City *

State/Province Zip/Postal Code *

Home Phone () - *

Fax () -

E-Mail

How would you like us to deliver the quote? *

Current Insurance

Why do you require Homeowners Insurance: *

How many Claims have you made in the last five years: *

Who is your current insurance carrier: * (if none, type "none")

What is your current premium: (required if currently insured)

Date of current policy expiration: *

Number of families occupying home: *

Types of occupancy:

Owner Occupied	Rented to Others
Second Home	Owner & Tenant

How did you hear about us?

Construction Type

Style of Home

Number of stories
(excluding basement)

Approximate Living Area (square feet)
(excluding basement)

Construction Year
(ex. 1886) (note: approximate if not sure)

Type of Foundation

Roofing Material

Roof last replaced
(year, original, or unsure)

Type of Heating

Oil/Gas burner replaced
(year, original, or unsure)

Location of Oil Tank

Amps in Electrical Service   (60,100,150,200)

Circuit Breakers

Electric System last updated
(year, original, or unsure)

Garage Type

# of Cars garage holds

Security Features   Dead Bolt Locks
Fire Extinguishers
Smoke Detectors (battery)
Smoke Detectors (hard-wired)
Burglar Alarm (Local)
Burglar Alarm (monitored)
Fire Alarm (Local)
Fire Alarm (monitored)

Central Air

Number of Bathrooms

Number of Fireplaces

Swimming Pool

Insurance Coverages
Note: All Fields are required.

What is the purchase price of the home: $

What is the Mortgage Amount of the home: $

What is the dwelling amount of your home: $
(this is the amount necessary to replace all structural elements and items attached to walls in your home)

Amount of Personal Liability Coverage to be quoted:

Amount of Building Deductible to be quoted:

Is Scheduled Personal Property Coverage required:
If required specify amounts:
Jewelry-$ Furs-$ Silver-$

Underwriting Questions

Have you filed for Bankruptcy in the last five years:

Do you have a Dog: No Yes -

Do You have a Trampoline No Yes

Please provide us with all details of any previous claims here. Also include any additional comments that would help us provide a more accurate quote: