Insurance Planning Services_17-0194-00

HOMEOWNERS QUOTE FORM
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

YESNO
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

ASPHAULT SHINGLESARCHITECTURAL SHINGESMETAL-EXT WALL FINISH
Fireplace No.
Type

GasWood
HVAC System

GASELECTRICHEAT PUMPWINDOW UNITS
UPDATES
WIRING YR
Wiring Yr Status

PartialCompleteContractorSelf/ CopperSelf/ Aluminum
Heating Yr
Heating Yr Status

PartialCompleteContractorSelf/ GasSelf/ Electric
Plumbing Yr
Plumbing Yr Status

PartialCompleteContractorSelf/ PVCSelf/ GalvSelf/ Other
Roof Yr
Roof Yr Status

PartialCompleteContractorSelf
Garage

Built InCarportAttached
How Many Cars
Porches/ Decks- Sizes
Swimming Pool
Swimming Pool Type

YESNO
Fenced

YESNO
Locking Gate

YESNO
Size
Depth
Diving Board

YESNO
Slide

YESNO
Trampoline

YESNO
Animals

YESNOBreed
Breed
Business on Premise

YESNO
Type
Mortgage/ Lein Holder

First NameLast Name
Escrow Billed

YESNO
Policy Number
Insured Billed
Correct Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Alarm

YESNO
Monitored

YESNO
Foreclosure

YESNO
Shortsale

YESNO
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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HOMEOWNERS QUOTE FORM