Homeowner Quote Sheet
QUOTE INFORMATION
Policy Type:
HO3
HO6
HO4
DF3
Occupancy
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Source
Escrow
Yes
No
Reason for Shopping
Referral Program Discussed
Yes
No
Escrow / Referral Source Contacted
Yes
No
Agent prompts: mention referral program, contact escrow/referral source, and explain agency value.
APPLICANT INFORMATION
Named Insured
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Marital Status
Second Named Insured
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Property Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
Format: (000) 000-0000.
Email
example@example.com
Occupation
Self-Employed
Yes
No
Business / Daycare?
Yes
No
If business/daycare, explain
If self-employed, solicit commercial lines.
PROPERTY & UNDERWRITING INFORMATION
Brush
Slope
Trampoline
Yes
No
Animals
In/Out Service
Sq. Ft.
Year Built
Slab
Yes
No
Pool
Yes
No
Spa
Yes
No
Diving Board
Yes
No
Slide
Yes
No
Bolted to Foundation
Yes
No
Water Heater Strapped
Yes
No
IF BUILT OVER 30 YEARS
Age & Type of Roof
Age & Type of Wiring
Age & Type of Plumbing
Age & Type of Heating
Additional Property Notes
Back
Next
CURRENT INSURANCE & LOSS HISTORY
Current Carrier
In Force?
Yes
No
Current Dwelling Amount
Auto Carrier Same Company?
Yes
No
Auto Carrier
Multi-Policy Quote Offered?
Yes
No
Losses - Last 3 Years
HOME INFORMATION (ZILLOW IF POSSIBLE)
# Stories
# Baths
# Car Garage
Attached?
Yes
No
# Fireplaces
# Chimneys
Roof Type
Air
Kitchen Update
Bath Update
Flooring - Wood %
Carpet %
Tile %
Other Home Details
COVERAGE INFORMATION
Dwelling Amount
Additional Structures
EQ Deductible
Liability
Umbrella
Deductible
If no EQ - Present Quick Quote
Yes
No
DISCOUNTS / OTHER
Fire / Burglar Alarm
Yes
No
Alarm Type
Central
Local
Sprinklered
Yes
No
Gated Community
Yes
No
Guard & Fence Over 6 ft
Yes
No
Homeowners Assoc.
Yes
No
Loss Assessment Amount $
Other Discounts / Notes
SCHEDULED ITEMS
Jewelry
Fine Art
Fur
Silver
Computer
Other
ADDITIONAL INFORMATION
Additional Information Notes
Submit
Should be Empty: