Home and Auto Quote Information Sheet
Barnum-Brown Insurance, Inc.
Insured #1 Name:
First Name
Last Name
Insured #1 Occupation:
Insured #1 Birth date:
Insured #1 Email:
example@example.com
Insured #2 Name:
First Name
Last Name
Insured #2 Occupation:
Insured #2 Birth date:
Insured #2 Email:
example@example.com
Home Phone Number:
Please enter a valid phone number.
Insured #1 Cell Phone Number:
Please enter a valid phone number.
Text? (Y/N)
Please Select
Yes
No
Insured #2 Cell Phone Number:
Please enter a valid phone number.
Text? (Y/N)
Please Select
Yes
No
Mailing Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Location Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Current Home Carrier:
Premium:
Exp Date:
-
Month
-
Day
Year
Date
Current Auto Carrier:
Premium:
Exp Date:
-
Month
-
Day
Year
Date
Upload current insurance declarations pages:
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Home Questions:
List any claims in last 5 years:
Is fire hydrant within 1000 feet?
Yes
No
Is central station reporting fire and burglar alarm present? Example:ADT
Yes
No
Are deadbolt locks present?
Yes
No
Are fire extinguisher(s) present?
Yes
No
Are smoke detectors present?
Yes
No
Year home was built?
Heat update year:
Heat type:
Central control thermostat?
Yes
No
Roof update year:
Roof type (asphalt shingles, metal, etc):
Electric update year:
Electric box type (Fuse or Breaker):
Wiring knob and tube or aluminum? (Yes or No)
Plumbing update year:
Plumbing type (PVC, copper, pex, etc):
Is there a woodstove present?
Yes
No
Is there a fireplace present?
Yes
No
Is there a fireplace insert present?
Yes
No
Are there any dogs?
Yes
No
What Breed?
Bite History?
Yes
No
Any other animals?
Yes
No
What type?
Is there a trampoline present?
Yes
No
Does trampoline have a net?
Yes
No
Is there a pool?
Yes
No
For above ground pool, is there a removable ladder when not in use?
Yes
No
For in ground pool, is there fence with locking gate?
Yes
No
Is there a diving board?
Yes
No
Are there any detached buildings?
Yes
No
If Yes, Describe:
Is there a home business?
Yes
No
If Yes, Describe:
Any farming by you or others?
Yes
No
If Yes, Describe:
# of Acres:
Any ATVs, snowmobiles, golf carts?
Yes
No
If Yes, Describe:
Any watercraft?
Yes
No
If Yes, Describe:
Any scheduled items such as jewelry, furs, silver, fine arts, guns, etc?
Yes
No
Describe items and value:
Do you or will you have a mortgage?
Yes
No
If new home, what is the purchase price?
Expected Loan Closing Date:
-
Month
-
Day
Year
Date
Dwelling Limit:
Detached Structures Limit:
Contents:
Liability Limit:
Medical Payments Limit:
Deductible:
Auto Questions:
Licensed drivers in the household: List all drivers separately, to add the next driver click the "Add Another Driver" button below.
Vehicles: List all vehicles separately, to add another vehicle click the "Add a Vehicle" button below.
Do vehicles with physical damage coverage have full glass coverage?
Yes
No
Liability Limit:
Uninsured Motorist Limit:
Medical Payments:
Towing?
Yes
No
Limit:
Rental Car Reimbursement?
Yes
No
Limit:
Rental Car Gap Coverage?
Yes
No
Limit:
Additional comments you feel might be pertinent to your quotes:
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