RJR Insurance - Auto & Home Rating Information
Name: Spouse: Address: Home Phone: Email: Occupation: Current Homeowners Insurer: City: Work Phone: Spouse Email Employer: Current Auto Insurer: Date of Birth: Date of Birth:
(952) 931-9999 * Fax (952) 931-0096
SSN: SSN: St/Zip; Cell Phone:
Automobile Information:
Driver – List ALL Drivers in Household Date of Birth License Number
Violations or Losses (Please list all violations of losses in the past 5 years for all Drivers:
Date: Explain Accident/Violation: Amount Paid:
Has any driver had a license suspended or revoke within the last five years? Has Any Driver Completed 55 Alive or other Defensive Driving Program? Indicate Driver(s) name: Vehicle Information:
Year: Make: Model: VIN:
Yes: Yes:
No: No:
Veh. Use
One Way/Annual Miles / / / / Y Y Y Y
Alarm? N N N N
Vehicle Use P=Pleasure, C=Commute, B=Business
Home Information - (Check appropriate box) Estimated Replacement Value: Type of Residence? Primary: $ Seasonal: Year Built? Secondary: Rental: Year Occupied:
Construction - (Check appropriate box) Frame? Stucco? Stone? Brick Veneer? Brick? Other? Finished Sq. Ft? Foundation Sq. Ft? Home Style - (Check appropriate box) # of Stories? Bi-Level? Multi-Level? Tri-Level?
Heating/Air Conditioning - (Check appropriate box) Gas Force Air? Electric? Wood Stove? Garage Heater? Central Air? Other? Window A/C?
Roof Material - (Check appropriate box) Asphalt? Wood Shakes? Shingles? Composition? Siding Material - (Check appropriate box) Aluminum? Steel? Stucco? Wood? Vinyl? Fireplace(s) Total in Home? Gas Insert? Exterior Structures Deck? Yes No Porch? Yes No Brick?
Baths – Indicate # of each # Full Baths? Half Baths? Tri-Level? # ¾ Baths? Whirlpool Tub? Yes Basement Full? Half? Garage # of Stalls? Tuck-Under? Finished Crawlspace? Attached? % Walkout?
Detached?
Sq. Ft. Sq. Ft.
Updating for Homes older than 20 years old Item Year Updated Full Htg/Furnace Plumbing Electrical Roof Security Distance to Fire Station? Distance to Hydrant Deadbolt Locks? Y Status of Home Occupied?
Partial Any Galvanized Pipe Y Fuses? Y N N
Within 3 Miles Within 500’ Smoke Detectors Vacant?
Within 3-5 Miles Within 1,000’ Alarm? Y N
Over 5 Miles Over 1,000’ If yes indicate type Major Renovation?
Under Construction?
Boats/Recreational Vehicles – Boats, Motorcycles, Snowmobile(S), ATV Type Year Make Model Serial Number Engine Size Value
FOR OFFICE USE ONLY
DATE QUOTE REQUESTED BY: ______________________________________ PRODUCER: ______________________________________
LIMITS Auto Limits to Quote: Liability: __________________________ Comp Ded: ____________ Collision Ded: ____________ _____________ ____________
Home Limits to Quote: Liability: ___________________________ Med Paymt: ____________ Deductible: Renters or Condo Limits to Quote: Dwelling: _____________ Pers Prop: __________ Liability: ____________ Deductible:
PRODUCER COMMENTS: