New Build and Dwelling Insurance Inquiry

New Build and Dwelling Insurance Inquiry
Name:

First NameLast Name
Phone Number:
Please enter a valid phone number.
Email:
example@example.com
Effective Date for Policy:

MonthDayYear
Date
Location Address for Property to be Insured:

Street Address

Street Address Line 2

CityState

Zip Code
County of Property to be Insured:
Year Home/Property was Built:
Is it a Primary or Secondary Residence:
Exterior Material of Home:
Roof Type and Age:
Foundation Type:
Living Area Sqft:
Number of Stories:
Garage (Yes/No): If yes, is the garage attached or detached?
Basement (Yes/No): If yes, include sqft and is it Finished out?
Any Porches (Yes/No): If yes, total sqft and are the porches covered or open?
Any other Structures: If yes, please list: type, size, roof, foundation, and value of structures
Any Swimming Pool/s (Yes/No): If yes, is there a locked fence around the pool or property?
Any Dogs (Yes/No): If yes, list the number and breed/s.
Livestock/Use of Property:
Water Supply: (Well or Public)
Distance to Fire Station and/or Hydrant:
Monitored by Alarm (Yes/No): If yes, what type of alarm system?
Coverage Value and Replacement Cost: (Please also list Deductible Value)
Personal Property (Estimated amount or %):
Do you want to include Liability Coverage:
Any Loss History/Claims:
Prior Carrier if any:
Payment Type: (Direct or Escrow?)
Comments:
Tell us a little more about your insurance needs. Please list any other additional information that may be relevant to the property to be insured.
Should be Empty: