Personal Information
Insured Name:
Location of Risk:
City:	State:   Zip:
Mailing Address (if different):
City:	State:   Zip:
Does risk have insurance   coverage now?:	Y   N       If "No", please explain below:
Note to agent requesting quote: We will not valuate this risk, we will only provide a quote for the amount of coverage requested.

Home Information
Year Home Was Built:		Square Footage (excluding garage and basement):	sq. ft.
If home is more than 20 years old, please provide updated information for the following:
Plumbing:
Heating:
Electrical:
Roofing:

Requested Coverages
Dwelling Coverage Amount:	Liability Amount:	Deductible Amount:
$	-- Select One -- No Coverage $100,000 $300,000 $500,000	-- Select One -- $ 500 $1,000 $2,500

 

Loss Information

Have there been any losses in the last 3 years?   Y   N     (if "Yes", please provide date, amount and type of loss below)

Structure Information
Type	# of Units	Dwelling Type	Construction
1 Story 1 1/2 Story 2 Story 3 Story Split Level Bi-Level Other	1 2 3 4 5	Primary Secondary Rented to Others	Frame Masonry Other
Foundation	Garage	Roof	Age of Roof
Basement Slab Raised Post & Pier	1 Car 2 Car 3 Car 4 Car None Attached Detached Basement Built-in Car Port None	Asphalt Shingle Tar & Gravel Wood Shake Concrete Tile Clay Tile Metal Other	yrs.

Features
Heating System	Swimming Pool	Distance of Fire Hydrant	Distance of Fire Station
None Electric Gas Oil Propane Solar Other	Yes	feet	miles
Security Alarm	Fire Alarm	Theft Alarm	Smoke Detector
None Monitored Not Monitored	None Monitored Not Monitored	None Monitored Not Monitored	Yes

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter them here.

Disclaimer: We may require more information to underwrite this risk.

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