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					                               HOMEOWNERS QUOTE

IS IT OK TO DO CREDIT CHECK AND CHECK FOR LOSSES?

DATE                                                  DATE OF BIRTH

NAME                                                  SOCIAL SECURITY #

ADDRESS                                               CITY LIMITS? YES/NO

PHONE                                                 FIRE DISTRICT


HAVE YOU LIVED HERE FOR LESS THAN 5 YRS?
IF YES, PREVIOUS ADDRESS-

WITHIN 5 MILES OF FIRE STATION?

WITHIN 1000 FEET OF FIRE HYDRANT?

APPROX. FAIR MARKET VALUE OF HOME-

ANY BUSINESS CONDUCTED ON PREMISES? YES/NO            IF YES, WHAT TYPE?

ANY FARMING?

SWIMMING POOL?    YES/NO       IF YES, FENCED IN? YES/NO

TRAMPOLINE? YES/NO

LIST ALL ANIMALS IN HOME:                        BREEDS OF DOGS:

ANY GUNS ON PREMISES? YES/NO        IF YES, ARE THEY LOCKED? YES/NO
                                    HAS OWNER RECEIVED FIREARMS TRAINING? YES/NO

#FAMILIES IN HOME:            #PEOPLE IN HOUSEHOLD:

#FULL-TIME RESIDENCE EMPLOYEES:

HAVE YOU BEEN CANCELLED FOR NON/PAYMENT OF HOMEOWNERS INS. WITHIN PAST 3 YRS?

ANYONE IN HOME CONVICTED OF ARSON IN LAST 7 YRS? YES/NO

ANY CLAIMS IN LAST 3 YEARS? YES/NO         IF YES, LIST TYPE, DATE, AND AMOUNT

YEAR HOUSE BUILT-             (IF MORE THAN 15 YRS OLD, COMPLETE FOLLOWING:
                            YEAR NEW ROOF:          YEAR NEW PLUMBING:
                           YEAR NEW HEATING:            YEAR NEW WIRING:

STYLE OF HOME:
NUMBER OF STORIES:                  SQ. FEET:
BRICK OR FRAME:                     TYPE OF SIDING:
ROOF TYPE:                           ASPHALT SHINGLES? YES/NO
FOUNDATION:   SLAB OR CRAWL SPACE
CENTRAL HEATING/AIR: YES/NO       IS HEAT SUPPLEMENTED BY WOOD OR COAL STOVE?

GARAGE TYPE: ATTACHED/DETACHED          # CARS                          YES/NO

# DECKS-                 #PORCHES-                    #BREEZEWAYS-
#FIREPLACES-             #FULL BATHS-                #HALF BATHS-

HOW MUCH COVERAGE WOULD YOU LIKE ON YOUR HOME?

DEDUCTIBLE-    $250   $500   $1000

PERSONAL LIABILITY LIMIT: $100,000    $300,000   $500,000

MEDICAL PAYMENTS: $1,000     $3,000   $5,000

EXTRA INSURANCE ON COMPUTERS? YES/NO

SMOKE DETECTORS? BATTERY/HARDWIRED

BURGLAR ALARM? LOCAL/CENTRAL

FIRE ALARM? LOCAL/CENTRAL

FIRE EXTINGUISHERS AND DEAD BOLT LOCKS? YES/NO

				
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posted:2/18/2011
language:English
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