Homeowners Insurance
Homeowners Insurance Proposal Request
Your Name:
Address:
City, State, Zip:
County:
Home Phone:
Work Phone:
Fax:
E-Mail Address:
Date of Birth:
Some of the following questions may require information contained on your current homeowners policy. You may leave comments or questions at the end of the questionaire.
Residence Information
HO Form
Select
Home Owner
Tenant/Renter
Condominium Owner
Inside City Limits?
Select
Yes
No
Primary Residence?
Select
Primary
Secondary
Year Built
Construction Type
Select
Frame
Stucco
Brick
Deductible Amount
Select
100
250
500
1000
2500
Replacement Value
Coverage Information
Personal Liability
Select
100,000
200,000
300,000
400,000
500,000
1,000,000
Medical Payments
Select
1000
2000
3000
4000
5000
10000
Replacement Cost Options
Replacement Cost on Dwelling
Replacement Cost on Contents
Protective Devices
Smoke Detectors
Dead Bolt Locks
Fire Extinguisher
Non Smoker
Central Station Burglar Alarm (rings at a monitoring center)
Central Station Fire Alarm (rings at a monitoring station)
Police Station Direct Alarm (rings at police station)
Fire Station Direct Alarm (rings at fire station)
Local Burlar Alarm (rings on the premises only)
Local Fire Alarm (rings on the premises only)
Automatic Sprinkler - All Areas
Automatic Sprinkler - Excluding Attic, Bath, Closet
Additional Coverages
Scheduled Property -
Enter Total Dollar Amount of Itemized Coverage for each Category
Silverware
Camera - Photo Equipment
Musical Instruments
Personal Furs
Personal Jewelry
Jewelry in Vaults
Guns
Golf - Sports Equipment
Computers - Electronics
Earthquake Coverage?
Select
No
Yes
(Not Covered unless you select coverage)
Flood Coverage?
Select
No
Yes
(Not Covered unless you select coverage)
Please list all claims and amounts paid for the last 3 years
Use this area for any special comments or coverages which need special attention.
Do you currently have homeowners insurance?
Yes
No
Who is your current homeowners insurance company?
When does your current homeowners insurance policy expire?
