Insurance Planning Services_17-0194-00

Insureds Name

First NameLast Name

Date of Birth

MonthDayYear

Occupation

How Long

Phone Number

Area CodePhone Number

Mobile #

E-mail

Spouse Name

First NameLast Name

Date of Birth

MonthDayYear

Occupation

How Long

Phone Number

Area CodePhone Number

Mobile #

E-mail

How was wealth Acquired (High Value Only)

Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Insured location Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

If New Home, Closing Date

MonthDayYear

Inside City Limits

County

Responding Fire Dept

Miles to Dept

Distance to Hydrant

Prior Carrier

Policy Coverage Dates

MonthDayYear

Prior Claims

Coverage Amount Desired

Deductible

Liability Limit

Year Built

MonthDayYear

Percentage of Construction

Full Bath

Half Bath

# Of Stories

Wings

Sq Footage

Flooring

Roof Type

Fireplace No.

Type

HVAC System

UPDATES

WIRING YR

Wiring Yr Status

Heating Yr

Heating Yr Status

Plumbing Yr

Plumbing Yr Status

Roof Yr

Roof Yr Status

Garage

How Many Cars

Porches/ Decks- Sizes

Swimming Pool

Swimming Pool Type

Fenced

Locking Gate

Size

Depth

Diving Board

Slide

Trampoline

Animals

Breed

Business on Premise

Type

Mortgage/ Lein Holder

First NameLast Name

Escrow Billed

Policy Number

Insured Billed

Correct Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Alarm

Monitored

Foreclosure

Shortsale

PLEASE LIST ANY OTHER INFORMATION NEEDED TO CONSIDER IN QUOTING: CUSTOM KITCHEN, BATHS, SOLAR PANELS, ETC… SCHEDULED JEWELRY, FIREARMS, ART, FURS, ETC

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