Auto Quote

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Personal Information

First Name	Last Name
Date of Birth	/ / mm/dd/yyyy
SSN#	(no dashes)
Property Address
City	State Zip
Home Phone	Work Phone Cell Phone
Best Time to Contact	Fax
Email Address
Send Quotes via
How Did you Hear About us?	Required

Insurance

Are you currently insured?	Yes No
Type of Property
Occupancy:	Owner Occupied Rented to Others Second Home/Vacation Vacant
Number of Claims on any property owned in the last 36 months?

Information about your Home

Construction of Home

Style of Home

Number of Stories

(excluding basement)

What year was the home built?

What type of Foundation supports the home?

Basement:

If basement is finished, square footage finished

Type of Roof

Date Roof Installed

Type of heating

Date furnace installed

Electrical last updated

How many amps rated

Garage Type

Number of vehicle garage holds

Security Features (check all that apply)

Smoke Detectors
Fire Extinguishers
Dead Bolts
Local Burglar Alarm (local horn)
Local Fire Alarm (local horn)
Central Station Burglar Alarm
Central Station Fire Alarm
(Central Station means connected directly to a monitoring facility)

Home Features

Central Air
Number of Full Bathrooms
Half Bathrooms
Number of Fireplaces
Swimming Pool

Insurance Coverage

If you are just purchasing home show purchase price: $

Mortgage Amount $

Dwelling Amount $

Personal Property $

Personal Liability $

Deductible $

Is Earthquake Coverage Requested?

No Yes

Do you need specific amounts of coverage for special items (jewelry, furs, silver, etc.)

No Yes

If yes, give amounts exl. $10,000

Jewelry	Electronics	With Breakage
Furs	Fine Arts	Yes No
Silver
Cameras

Underwriting Questions

Underwriting qualification now includes credit. Credit has become a major factor in obtaining insurance in most all states, so please be aware that where applicable, rates will be quoted based on your response below.

Filed for Bankruptcy in the last 5 years	No Yes
Is Your Credit Rating	Good Excellent Fair Poor
Do you have a dog (If yes give breed )
Other types of insurance you would like to receive information	Auto Business Flood

Additional Comments

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