| Name |
|
| Address |
|
| City: |
|
| State: |
|
| Zip: |
|
| Email |
|
| Phone |
|
| Fax |
|
| Current Homeowners Insurance Company |
|
| Date Insurance Expires |
|
| Current amount of coverage |
|
| Limited Liability |
|
| Deductible |
|
| Hurricane or Wind/Hail Deductible |
Other
|
| Year home was built |
|
| Square footage of living
area |
|
| Number of claims in last 3 years |
|
| If you have had claims, please list them |
|
| |
| HOUSE SPECIFICATIONS: |
|
|
|
| Type
|
Construction
|
| Foundation
|
Roof
|
| Garage
|
Garage Type
|
| Number of Full Bathrooms |
Number of Half Bathrooms
|
| Swimming Pool
|
Is the swimming pool fenced in? |
| Do you have dogs? |
If so, how many dogs?
|
| Heating Type | |
| |
| Discounts - Check all that
apply: |
| Protective devices (smoke detectors, fire extinguishers,
dead bolt locks) |
|
| Age 55+ and retired |
|
| Central station alarm |
|
| Hurricane shutters |
|
| Renovation discount (new wiring, plumbing, roof,
A/C in last 15 years) |
|
| Home and Auto Discount |
|
Current Automobile Insurance Company
(Auto owners may receive a discount) |
|
| |
| How would you like us to
contact you?
(check all that apply) |
| email: |
|
| phone: |
|
| fax: |
|
| |
|
Additional information or comments:
|
|
|
