| Agency Name: |
Phone:
|
| Agency Contact: |
|
| E-mail Address: |
|
| Applicant Name: |
Occupation:
|
| Applicant Phone: |
DOB:
|
| Location Address: |
|
| City: |
State:
Zip:
|
|
| New Purchase: |
Y
N
Prior Carrier:
Prior Premium:
|
| Lapse in Coverage: |
Y
N
If Yes, Date Of Last Coverage:
|
| If Lapse, Explain: |
|
| Occupancy: |
|
| Number of Families |
|
| Distance to Brush |
Distance to Fire Hydrant
|
| Protection Class (1 - 10): |
Distance to Fire Department
|
| Losses: |
Any losses in the Last Five (5) Years? Yes
No
|
| If Yes, Explain: |
|
|
| Dwelling Amount: |
|
| Extended Replacement Cost: |
125%
Yes
No
|
| Roof Type: |
|
| Deductible: |
|
| Year Built: |
Sq Footage:
|
| Home Updates: |
Roof:
Plumbing:
Electrical:
Heating:
|
| Protective Devices: |
Burglar Alarm: None
Local
Central
| Smoke Detectors: Yes
No
|
|
Fire Alarm: None
Local
Central
| Interior Sprinklers: Yes
No
|
| Personal Property: |
Replacement Cost Y
N
|
| Personal Liability: |
|
| Water Back Up: |
|
| Personal Injury: |
Y
N
Identity Fraud Y
N
|
| Gated Community: |
Yes
No
|
| Animals? |
Yes
No
|
| If yes, what kind: |
|
| Wood Burning Stove: |
Yes
No
|
| Earthquake: |
Yes
No
| EQ Deductible:
10%
15%
|
| |
Notes |
| |
|
| |
|
|
|
