Personal Home

Personal Home
Name*

First NameLast Name
E-mail*
example@example.com
Phone Number*
Property Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Social Security
Providing your Social Security number helps us run an accurate quote and may be used for identity verification purposes. If you do not feel comfortable providing it here, leave this blank
Property Details
Year Built*
Type of Home*

Single-FamilyMulti-FamilyCondoTownhouseMobile Home
Square Footage*
Construction Type*

WoodBrickStuccoOther
Roof Type*

AsphaltMetalTileOther
Year of Roof Installation/Last Replacement*
Number of Stories*
Garage*

YesNo
Garage Attached/Detached*

AttachedDetached
Garage Number of Cars*
Home Features
Number of Bedrooms*
Number of Bathrooms*
Swimming Pool*

YesNo
Deck/Patio*

YesNo
Fireplace*

YesNo
Security System*

YesNo
Fire Protection System (Sprinklers)*

YesNo
Current Insurance Information
Do you currently have homeowners insurance?*

YesNo
Current Insurance Company*
Policy Expiration Date*

MonthDayYear
Current Premium*
Any claims in the last 5 years?*

YesNo
If yes, describe each claim (date, type of loss, amount claimed)*
Desired Coverage Information
Coverage Amount (for dwelling)*
Desired coverage for main structure (the home itself)
Personal Property Coverage*

50% of dwelling coverage (standard)60% of dwelling coverage70% of dwelling coverageCustom
Full Replacement/Actual Cash Value*

Full ReplacementActual Cash Value
Liability Coverage*

$100,000 (standard)$300,000$500,000Custom
Deductible Preference*

2%3%5%
Wind and Hail Coverage?*

YesNo
Wind and Hail Deductible*

2%3%5%
Additional Coverage Options

Water BackupScheduled Personal PropertyEquipment BreakdownFlood InsuranceEarthquake Insurance
Occupancy Information
Owner-Occupied or Rental Property*

Owner-OccupiedRental
Primary Residence or Secondary/Vacation Home*

Primary ResidenceSecondary/Vacation Home
Do you have pets?*

YesNo
If you have pets, what kind and how many?*
Additional Questions
Do you run a business from home?*

YesNo
If yes, explain the nature of the business*
Do you plan to make any major renovations?

YesNo
If yes, describe the renovation*
Is there a mortgage?*

YesNo
Any additional comments or requests for coverage?
Should be Empty:

Personal Home

Property Details

Home Features

Current Insurance Information

Desired Coverage Information

Occupancy Information

Additional Questions