Homeowner's Insurance Quote Form

Inter-Ocean Insurance Agency
Homeowner's Insurance Quote Form
Customer Information
Island

St CroixSt Thomas / St John
Title*

Mr.Mrs.MissOther
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Marital Status*

SingleMarriedDivorcedWidow(er)
Spouse Name

First NameLast Name
Spouse Date of Birth

MonthDayYear
E-mail*
example@example.com
Phone Number*
Residential Address*

Residential Address

Residential Address Line 2

CityState / Province

Postal / Zip Code
Use my Residential Address as my Mailing Address
Mailing Address*

Mailing Address

Mailing Address Line 2

CityState / Province

Postal / Zip Code
Coverage Limits
Do you currently have homeowner's insurance?*

YesNo
Would you like to upload the Declarations Page for your current policy?*

YesNo
Declarations Page

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	Limit
Dwelling
Other Structures
Personal Property
Liability
Medical Payments
Windstorm Coverage Requested?

Underwriting Information
Do you currently have homeowner's insurance coverage?

YesNo
Current Homeowner's Insurance Carrier*
Any homeowner's insurance claims in the last 5 years?*

YesNo
Please describe
Do you have pictures of the home that you would like to upload?*

YesNo
Pictures of the Home

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Insured is*

OwnerTenantLessee
Other occupants in building?*

YesNo
Please describe other occupants
Is building rented to others?*

YesNo
Please describe who it is rented to
Type of Building*

Single Family2-4 FamilyCondominium
Year Built*
Year Purchased*
Square Footage of Building*
Square Footage of Porches/Decks*
Number of Stories*
Have you done major alterations or improvements?*

YesNo
Please describe alterations or improvements
Roof Structure*

Reinforced concreteExposed beamWood rafter (open system for corrugated metal)Wood trussesSteel raftersSteel joists with steel deckingOther
Roof Structure Anchor System*

Hurricane clips (secured to bond beam)Re-bar from slab through rafter endNoneOther
Laths or Purlins*

Not applicableNot more than 24" apartMore than 24" apartNailed or screwed to each rafter
Roof Cover*

Aluminum or corrugated metalPaintedStanding seamEnamel finishPlastic tileMembrane CoatingOther
Roof Cover Fastenings*

Not applicableNailsScrewsNails & screwsStaplesOther
Intervals Between Fastenings*

Not applicableLess than 8"8"12"16"Other
Roof Overhang*

None2'3'4'Other
Exterior Walls*

Reinforced concreteReinforced concrete blockHollow concrete blockBrick or StoneWood studSteel stud3-D PanelOther
Hurricane Shutters?*

Yes, all windowsYes, all windows and all doorsPartial, some windows and/or doors do not have shuttersNo
Type of Shutters

Roof type steelHinged wood (permanent)Steel panels (portable)Anchor bolts to receive plywoodImpact glassIron grill workAluminum "Miami-style" louversNoneOther
Please explain how exterior openings will be protected in the event of a hurricane
Has electrical been rewired?*

YesNo
Year that it was rewired
Miles to fire department*
Number of fire extinguishers*
Are fire extinguishers properly tagged and serviced?

YesNo
Number of smoke detectors*
Other water sources

CisternPoolOther
Fire detection system?*

YesNo
Burglar alarm system?*

YesNo
Pictures, Appraisal, Listing Sheet or Other Helpful Information

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Should be Empty:

Inter-Ocean Insurance Agency

Homeowner's Insurance Quote Form

Customer Information

Coverage Limits

Underwriting Information