"Our success is not because of the coverage we offer. It's because of the people who write the policies."


Difficult to Place Homeowner Quote

Agency Name: Phone:
Agency Contact:
E-mail Address:
Applicant Name: Occupation:
Applicant Phone: DOB:
Location Address:
City: State: Zip:
 

Coverage Information

Prior Carrier: New Purchase: Y N Lapse in Coverage: Y N
Occupancy: Primary Secondary Rental Secondary Rental Builders Risk
Builders Risk: 3 months 6 months 12 months
Vacant: 3 months 6 months 12 months
Number of Families One Two Three Four
Distance to Brush Distance to Fire Hydrant
Protection Class (1 - 10): Distance to Fire Department
Losses: Any losses in the Last Three (3) Years? Yes No
If Yes, Explain:
 

Home Information

Home Updates: Roof: Plumbing: Electrical: Heating:
Year Built: Sq Footage:
Dwelling Amount:
Roof Type: Comp Wood Shake Tile Slate Metal
Protective Devices: Burglar Alarm: None Local Central | Smoke Detectors: Yes No
Fire Alarm: None Local Central | Interior Sprinklers: Yes No
Extended Replacement Cost: 125% Yes No
Personal Property: Replacement Cost Y N Enhanced Coverage Y N
Personal Liability: $100K $300K $500K $1 Million
Water Back Up: `$5,000 $10,000 $25,000
Personal Injury: Y N Identity Fraud Y N Loss Assessment $5000 $10000
Gated Community: Yes No
Animals? Yes No
If yes, what kind:
Deductible: $1,000 $1,500 $2,500 $5,000 $10,000
Wood Burning Stove: Yes No
Earthquake: Yes No | EQ Deductible: 10% 15%
 

Notes