This information will be used only for providing a cost of insurance.  Providing this information does not provide or bind any coverage of insurance.

 

 

Property Information:

Home ownership: I own my home I own, and rent to others I rent   Occupancy: I live there I move in within a year I don't live there   Business or farming use: No Yes   Property street address:   Property zip code:   Property type: Single Family Home Cooperative (co-op) Condo w/4 or fewer stories Condo w/5 or fewer stories Town Home Multi Family dwelling   Property is used as: Primary Residence Second/Vacation Home Investment Property   Property quality: Standard Economy Luxury   Number of smokers in home: 0 1 2 3 4 5+   Number of pets: 0 1 2 3 4 5+   Type of dog (if any): None Doberman German Shepherd Rottweiler Wolf Hybrid Chow Mix of any of the above Other   Year the house was built: 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 Prior 1900   Estimated square footage: 500 750 1000 1250 1500 1750 2000 2250 2500 2750 3000 3250 3500 3750 4000 4250 4500 4750 5000 over 5000 sqft   Floors excluding basement: 1 2 3 4 5+

	Number of units:	1 2 3 4 5 6 7 8 9 10+
	Number of rooms:	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15+
	Number of bedrooms:	1 2 3 4 5+
	Number of bathrooms:	1 1.5 2 2.5 3 3.5 4 4.5 5+
	Is there a garage?	Yes, Attached to Home Yes, Not Attached to Home Yes, Carport No Garage
	Describe the basement:	No basement at all Less than 50% finished More than 50% finished
	How is the home heated?	Gas Electric Oil - tank in basement Oil - tank underground Oil - tank above ground
	Type of exterior walls:	All Brick Cinder Block Drivet Log More than 50% Brick Stucco Vinyl Siding Wood Wood Shingles Not Sure Other
	Type of roof:	Asphalt Colored Granules (Common) Wood Shake Treated Wood Slats Tile/Clay Shingles (Spanish) Metal Flat Roof Not Sure Other
	Within 1000 feet of hydrant?	Yes No
	Distance to manned fire dept.:	Within 5 miles Within 10 miles Over 10 miles
	Security system installed?	No security alarm system Yes, alarm in home only Yes, w/ monitoring company
	Any claims in the last 5 years?	No 1 2 3

 

Check items below that are part of the residence (please check all that apply):

Deadbolt Locks Wood Stove Smoke Detectors Central A/C Fireplace Swimming Pool Uncovered Patio/Deck Covered Patio/Deck Tennis Court Fire Extinguisher Trampoline Indoor Fire Sprinkler

 

Current Insurance Information:

Are you currently insured? Yes No   Current insurance company: (Independent) AAA Insurance Acacia Life Accident Fund Insurance Company of America ACE USA Acordia National Acuity Aegis Security Aetna Affirmative Affordable Life & Health Insurance AFLAC AIG Aim Alfa Life Insurance Allianz Allied (AMCO Insurance) Allstate Insurance Company ALPHA Amalgamated Life Insurance American Automobile Association American Equity Investment Life American Family Insurance American General Insurance American Insurance Agency American Mayflower (First Colony Life Insurance) American Medical Security Life Insurance Company American Modern (the Midland Company) American National Insurance Company American National Property and Casualty American Pioneer American Progressive American Reliable American Republic American Sentinel American Skandia American Strategic Insurance American United Life Insurance Ameriprise Auto & Home Insurance Amerisure Ameritas Amica Anthem Blue Cross & Blue Shield Aon Corporation Arbella Argonaut Group, Inc. ASSIST-CARD Association Field Services Assurant Assurity Life Insurance Asuris Northwest Health Atlantic Mutual Austin Mutual Auto-Owners Insurance Aviva Life Badger Mutual Balboa Insurance Group Bankers Life and Casualty Company Banner Life Insurance Baptist Life Association BCS Life Insurance Benefitical Life Insruance Berkshire Life Insurance BISYS Commercial Insurance Services, Inc. Blue Cross/Blue Shield Boston Mutual Bristol West Insurance Brooke California Casualty Insurance CapitalOne CarInsurance.com Celtic Insurance Co. Chubb Corporation Church Mutual CIGNA Cincinnati Financial Corporation Citizens Clements International CNA College Health IPA Colonial Colonial Penn Columbian Life Combined (AON) Conseco Continental General Cotton States Country Insurance & Financial Services Coventry Cuna Mutual Group Deerbrook Insurance (Allstate) Dewitt Of Mid-Rivers Electric Insurance Company EMC Equitable Erie Insurance Esurance Expatriate Insurance Family Heritage Life Farm Bureau Insurance Farm Family Life Farmers & Traders Life Farmers Insurance Federated Fidelity Fireman's Fund Insurance Company First Acceptance First American First Investors Life First Security (Ohio Casualty Group) Foremost Foresters Forethought Financial Fortis Insurance Company Frankenmuth Mutual Insurance Company GAINSCO Auto Insurance Garden State Life Insurance Company Geico Genworth Life & Annuity Gerber Life Globe GMAC Insurance Golden Rule Insurance Company Golden State Mutual Grange Mutual Casualty Group Great American Insurance Company Great West Greater Beneficial Union of Pittsburgh Group Health Cooperative Group Health Inc. Guardian Insurance Guardian Life Insurance Company Guide One Insurance Hanover Lloyd's Company Harvard Community Health Plan Hastings Mutual Insurance Company Hawkeye Security Health Net Health Net of Arizona Health Net of Oregon Health Plan of Nevada HealthPartners Heartland Insurance Heartland Insurance Horace Mann Humana IFA Auto Illinois Mutual Life Infinity Auto Insurance Company Infinity Property & Casualty ING Insurance Insurance Services of America Integrity Life Intermountain Health Care Investors Heritage Island Insurance Jackson National Life John Hancock Kaiser Foundation Health Plan Kaiser Permanente Kansas City Life Insurance Company, Inc. Liberty Mutual Liberty National Life Insurance Company Life Insurance Co of the Southwest Life Investors Insurance LifeWise Health Plan of Arizona LifeWise Health Plan of Oregon LifeWise Health Plan of Washington Lincoln Financial Group Lincoln Heritage Life Madison National Life Manhattan Life Manulife Financial Markel American Markel Corporation Marquette National Life Mass Mutual Medica of Minnesota Medical Mutual Mega Life Merastar Mercury Metropolitan Life Insurance Company (MetLife) Mid-West National MiddleOak Middlesex Midwest Family Mutual Midwest National Life Ins. Midwest National Life Insurance Company Millers Mutual Minnesota Life Minnesota Life Insurance Company Missouri Employers Mutual Modern Woodmen of America Monumental Life Morgan Stanley Mountain Laurel Mutual of America Mutual of Enumclaw Mutual of New York Mutual Of Omaha NASE National Farmers Union National Indemnity National Insurance Agency National Interstate National Life National Merit National Security Life & Annuity Nationwide New England Financial New York Life New York Life Insurance Co. NLI (Nippon Life) North American North Carolina Mutual North Pacific Northe Pointe Northern Capital Northland Northwestern Mutual Ohio Casualty Old Mutual OneBeacon Insurance Group Oregon Mutual Oxford Health Plans, Inc. Pacific Life Insurance Pan-American Life Insurance Partners Mutual Patriot General Patriot Mutual PEMCO Penn Mutual Pennsylvania Life Pennsylvania Natl Peoples Benefit Life Perico Life Permanent General Companies, INC. (The General) Philadelphia Insurance Phoenix Physicians Mutual Pioneer Life Pioneer Mutual Pioneer State Mutual Premier Presidential Life Primerica Insurance Principal Financial Group Progressive Protective Life Prudential Pyramid Life Quality RBC Insurance Reliance Standard Life ReliaStar Life Republic Indemnity Response Insurance RiverSource Life Rockford Mutual SAFECO Insurance Safeway Insurance Group Sagicor USA, Inc., American Founders Life Savings Bank Life Insurance Secura Security Mutual Life Sentry Group Shelter Co. Shelter Insurance Companies Shelter Life Insurance Company Shenendoah Solid Insurance Group Southern Farm Bureau Standard Security Life State Auto Insurance State Farm Stonebridge Life Sublimity Insurance Sun Life Insurance Sutter Symetra Life The General The Hartford The St. Paul Travelers Companies, Inc. The Standard Life The State Life Insurance Co. Thrivent Financial for Lutherans Titan Tower Transamerica Occidental Travelers Twenty-First Century Insurance Twin City Fire UGA Unicare Unigard Insurance Union Union Bankers Life Union Central Life Union Mutual Fire Union Standard Insurance United American United Financial United Fire & Casual United Heritage Life United Heritage Property & Casualty United Security United Services Automobile Association UnitedHealthCare (Pacificare) Unitrin Unitrin Direct Auto Insurance Unity Mutual Universal American Financial Corp. Unum USF&G Utica Vigilant Viking Co of WI Vista Healthplan of South Florida Wausau Insurance Companies Wawanesa (California) Wellington Wellpoint West American West Bend Mutual Insurance Company West Coast Life Western & Southern Life Western Mutal Western National Western Reserve Life Western Southern Life Westfield Insurance William Penn Life Windsor Wisconsin Mutual Workmans Auto WorldWide Yosemite Zurich North America Not Listed

	When does your policy expire:	30 Days 60 Days 90 Days 120 Days More than 120 Days Not Sure
	Property continuously insured for:	Years 0 1 2 3 4 5 6 7 8 9 10+ ,  Months 0 1 2 3 4 5 6 7 8 9 10 11

 

Requested Coverage:

Requested dwelling coverage? $75,000 $100,000 $125,000 $150,000 $175,000 $200,000 $225,000 $250,000 $275,000 $300,000 $325,000 $350,000 $375,000 $400,000 $425,000 $450,000 $475,000 $500,000 $525,000 $550,000 $575,000 $600,000 $625,000 $650,000 $675,000 $700,000 $725,000 $750,000 $775,000 $800,000 $825,000 $850,000 $875,000 $900,000 $925,000 $950,000 $975,000 $1,000,000 $1,250,000 $1,500,000 $1,750,000 $2,000,000 $2,250,000 $2,500,000 $2,750,000 $3,000,000   Requested deductible: $100 $250 $500 $1000 $2500 $5000

	Requested liability:	$100,000 $300,000 $500,000 $1 million umbrella $2 million umbrella
	Coverage on personal articles?	Yes No

 

Personal Information:

Occupation: Computers --Graphics --Operator/Technician --Programmer Engineering --Aerospace --Chemical --Civil --Electrical --Mechanical --Nuclear --Other Construction --Contractor --Electrician --Installer --Mechanic --Painter --Plumber --Welder Education --Administration --College Professor --Professional Instructor --Teacher Healthcare --Administration --Dentist --Dental Technician --Lab Technician --Nurse --Paramedic --Pharmacist --Physician --Surgeon --Psychiatrist --Psychologist --Social Worker Hospitality --Airline Employee --Hotel Services --Restaurant Services --Travel Agent Manufacturing --Assembly --Machine Operator --Maintenance --Printing Professional --Accounting --Architecture --Art/ Photography --Entertainment --Financial Services --Insurance --Interior Design --Journalism --Law/Legal Services --Marketing & Sales --Performing Arts --Real Estate --Sports/Fitness/Nutrition Private Sector --Child Care --Cleaning Services --Homemaker --Landscaping/Gardening --Personal Assistant Public Service --Civil Service --Economic Admin --Environmental Admin --Executive Legislative --Fire Fighter --Government Employee --Human Resources --International Affairs --Justice Department --Public Safety --Military Officer --National Security --Police Department --Postal Service --Public Transportation --Social Worker Retail --Auto Sales --Consumer Sales --Consumer Services --Management --Merchandising --Product Sales --Security Other-Not Listed Retired Self Employed Student Unemployed Veteran   Date of birth: (mm/dd/yyyy) / /   Gender: Female Male

	Credit history:	Excellent Some Credit Problems Major Credit Problems Bankruptcy 3-6 years ago Bankruptcy 1-3 years ago
	SSN: (optional)	- -
	Martial status:	Single Married Divorced Separated Widowed

 

Your contact information will be kept private and secure:

First name:   Last name:   Home telephone: - -   Alternate telephone: (optional) - -   Best time to contact: Anytime Morning at Home Morning at Work Afternoon at Home Afternoon at Work Evening at Home Evening at Work Weekends   Email:

	Address:
	City, State:	, AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
	Zip:
	How long have you lived there?	Years 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20+ ,  Months 0 1 2 3 4 5 6 7 8 9 10 11
	Comments: