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					                                                                                                                  Rev. 4 /2008
                                                Homeowners/Dwelling Quote

Applicant’s Name: ________________________________________________________ Producer: __________________________
Mailing Address: __________________________________ City: _______________________ State: ________ Zip: _________
County: __________________________________________ Phone (H): ___________________ Phone (W/C): ________________
                                                     EMAIL:__________________________________________________
Property Location: _________________________________ City: _______________________ State: ________ Zip: _________
County: __________________________________________ Feet to Hydrant: ______________ Miles to Fire Dept: ____________
Occupant Information:
Name:         SS#                        Date of Birth:       Relationship:            Occupation/Education Level:



Please check one: □ HO3            □ HO4             □ HO6           □ Dwelling/Fire     Settlement/Eff. Date:______________
Section 1 Limits: Property                                   Section 2 Limits: Liability
Coverage A Dwelling                $______________           Coverage E Personal Liability     $______________
Coverage B Other Structures        $______________           Coverage F Medical Payments       $______________
Coverage C Personal Property       $______________           Deductible:                       $______________
Coverage D Loss of Use             $______________
Additional Coverages                                              Additional Coverages
Water b-up/Sump Pump                                              Personal Injury                  Loss Assessment
Business Prop/Pursuits                                            ID Theft
Building Additions & Alterations                                  Sinkhole/Earthquake              Ordinance of Law
Dwelling Information
1.    Year Built                     _________                   Date Purchased       _________
2.    Type of Kitchen                Builder’s Grade / Custom
3.    Date of Updates:               Heating _____ Wiring _____                    Plumbing_____ Roof _____
4.    Construction Type:             □ Frame □ Masonry Veneer             □ Masonry         □ Other: _________
5.    Exterior Wall Materials        _________
6.    Style of Home                  _________
7.    Roof Type:                     □ Peaked          □ Flat                      Materials: _________________
8.    Number of Families:            □ One-family      □ Two-family                □ Three family □ Four family
9.    Row or Town home?              _________         End / Center Unit?          How many units in row? _________
10.   Square Footage:                _________         # of floors: _____          # of Bedrooms: _____
11.   Number of bathrooms:           Builder’s Grade: Full _____Half _____ Custom: Full _____Half _____
12.   Basement:                      □ Finished                  □ Unfinished      Square footage: _________
13.   Attic:                         □ Finished                  □ Unfinished
14.   Number of Fireplaces:          _________         Number of Wood Burning Stoves? _________
15.   Primary Heat Source:           _________         Is there an underground fuel tank? _________
16.   Central Air?                   □ Using heating Ducts       □ Using Separate Ducts □ None
17.   Garage Type:                   □ Attached        □ Detached         □ None            # of Cars: _________
18.   Deck or Patio?                 □ Yes             □ No               Square footage: _________
19.   Other structures on premises? _______________________________________________________________________________
20.   Type of Pool:                  □ In-ground       □ Above-ground         None          Fenced:                   □ Yes
           □ No              Diving Board/Slide:       □Yes □No
21.   Trampoline on premises:        □ Yes             □ No
22.   Animals or Exotic Pets?        □ Yes             □ No If yes, state breed/type: __________ Bite History/Training___________
23.   Protective Devices:            □ Fire Extinguisher □ Deadbolt Locks □ Smoke Detectors □ Sprinkler System
24.   Alarms:                        □ Central Burglar      □ Central Fire       □ Local Burglar          □ Local Fire
25.   Current Carrier:       _______________________             Expiration Date: ____________       Policy #: _____________
              Dec Page Attached:         □ Yes                   □ No
Loss History      Date                      Type                     Description                                Amount



Additional Insured
Mortgagee Name                     Address and Loan #                                                                Mtgee Billed?
                                                                                                                         Y N
Rev. 4 /2008

				
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Description: Quote Worksheets document sample