Homeowner’s Policy form

Homeowner’s Policy Quote
Name(s) of Homeowner(s)*
E-mail address*
Birth Dates of Purchasers*

MonthDayYear
Birth Dates of Purchasers

MonthDayYear
Social Security Number
Method of communication*

PhoneEmail
Phone Number 1*

Area CodePhone Number
Phone Number 2

Area CodePhone Number
Address of premise needing insurance*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Previous address if less than 3 years

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date of Purchase

MonthDayYear
Purchase Price
Projected Closing Date

MonthDayYear
Amount of Total Mortgage Dept
Mortgage Company
Distance to Fire Hydrant
Distance to Primary Responding Fire Department

Homeowner’s Policy Continued
Group or Association Affiliation
Year Built
Total Square Footage (not including finished basement)
Number of Stories
Garage?

YESNo
If Yes:

AttachedDetached
Construction of House
% Frame*
% Brick*
% Stucco*
% Other*
Other. Please Explain
Percent of Finished Area or Square Foot
Foundation of House

Pier and BeamBlockPoured ConcreteOther
Number of Bathrooms
Full
Half
3/4
Flooring
% of Hardwood
% of Carpet
% Tile
% of Other
Describe Other