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Homeowners Insurance
Contact Information
Name:
Home Phone:
Cell Phone:
Email:
Address:
Social Security Number:
Date of Birth:
Company Name:
Policy Type:
Homeowners
Condominium
Renters
Year Built:
Square Feet:
Number of Stories:
Number of Baths:
Full:
Half:
Heating:
Central
Floor
Wall
Electrical:
Circuit Breaker
Fuse
Foundation:
Slab
Raised
Air:
Central A/C
Other
No A/C
Exterior Walls:
Frame/Stucco
Wood Siding
Concrete Block
Brick/Masonry
Log
Other
Roof:
Wood Shake
Composition
Clay Tile
Slate
Concrete Tile
Flat
Other
Garage:
Attached
Detached
Built-in
# of Cars
Fireplaces:
# of Chimneys:
# of Hearths:
Pools:
No
Yes
Jacuzzi:
No
Yes
Alarms:
Fire
Burglary
Both
Fire Sprinklers:
No
Yes
Earthquake Retrofitted:
No
Yes
Business on Premises:
No
Yes
Built on a Hill or Slope:
No
Yes
In a Brush Area:
No
Yes
Do you have any pets?
No
Yes
If yes, what type and breed:
Distance to Fire Hydrant:
Distance to Fire Station:
Losses in the last 5 years:
Current Coverage Information
Loss Assessment Coverage (Condo Only)
10,000
20,000
30,000
40,000
50,000
Coverage A Amount (Dwelling):
Coverage B Amount (Other Structures):
Coverage C Amount (Personal Property):
Coverage D Amount (Loss of Use):
Coverage E Amount (Personal Liability):
Coverage F Amount (Medical Payments):
Deductible:
Comments
Comments:
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