Smith-Altman | Personal Property Quote Request

Smith-Altman | Personal Property Quote Request
Please fill out this form completely to have one of our representatives contact you with a detailed quote. No coverage is bound until you are contacted by one of our representatives.
Name

First NameLast Name
Date of Birth
E-mail
Phone Number

Area CodePhone Number
Current Insurance Carrier
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Driving Directions
Property Information
Type of Home

HouseMobile Home
Year Built
Construction Type
Basement?

YesNo
Roof Type
# of Stories
# of Baths
# of Rooms

Year Updated:

	Roof	Wiring	Plumbing	Heating
Year

Square Feet
City Limits

InOut
Trampoline?

YesNo
Porches or Decks?

YesNo
If yes, how many and area?
Central Heating?

YesNo
If no, choose one:
Supplemental Heat?

YesNo
If yes, select type:
Satellite/s or Antenna/s?

YesNo
If yes, how many Satellites?
If yes, how many Antennas?
Any farm activity on premises?

YesNo
Barns

YesNo
If yes, give detail (Area, Construction, Etc.)
Farm Equipment?

YesNo
If any, list (Year, Make, model, and serial number)
Swimming Pool?

YesNo
Above/Below Ground?
Fence?
Losses? (Past 3 Years)

YesNo
If any, give date and describe what happened.
Have you been cancelled, declined, or nonrenewed by an insurance company in the past 3 years?

YesNo
Acreage:
Animals:
Livestock:

Please state the distance to the nearest Fire Hydrant and Fire Department below.

	Fire Hydrant (feet)	Fire Department (miles)
Distance

Please check all the Protective Devices located on the property.

Fire ExtinguisherDead Bolt LocksSmoke DetectorsSecurity System
Remarks:
Please note that no coverage is bound by sending us this quote information. Only a signed application, after the entire process is complete, will activate insurance coverage.
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