| Information
About You |
First Name
|
Last Name
|
|
Date of Birth
|
Social Security Number
|
|
Address
|
City
|
State - ZIP
|
Phone
|
Fax
|
E-Mail
|
| Home
Description |
Construction
Brick
Frame
|
Number of families
in dwelling
1
2
3
4 or more
|
Please advise the
date the
following items have been updated
if the home is over 20 years old.
Plumbing
Heating
Electrical
Roof |
Do you have a
central station alarm?
Yes
No
|
Is your home within
3 miles from a Fire Station?
Yes
No
|
Is your home within
500
feet from a Fire Hydrant?
Yes
No
|
Do you have smoke
detectors?
Yes
No
|
Do you have fire
extinguishers?
Yes
No
|
Do you want replacement
cost
coverage on your contents?
Yes
No
|
Do you own dogs?
Yes
No
|
Are you a non-smoker?
Yes
No
|
If you own autos,
would you be
interested in combining the autos
with the homeowners policy
for additional discounts?
Yes
No
|
| Coverage
Limits |
Dwelling
Contents
Liability
|
Deductible
|
List any items and
its value
which you desire to have scheduled for an agreed amount,
i.e.. Jewelry, Furs, Silverware:
|
| General
Information |
|
Have
you had any homeowner claims or losses within the last 3 years? If so,
please explain:
|
Do you have a swimming
pool?
Yes
No
|
If so, is the pool
completely fenced in?
Yes
No
|
|
|
Any
person who, with intent to defraud or deceive, submits an application
or files a statement of claim containing any false, incomplete or misleading
information, or helps in any manner to commit a fraud against an insurer,
may be subject to civil penalties and criminal prosecution for insurance
fraud.
|
|
|
