Homeowner's Insurance Quote Form

Inter-Ocean Insurance Agency
Homeowner's Insurance Quote Form
Customer Information
St CroixSt Thomas / St John
Mr.Mrs.MissOther
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
SingleMarriedDivorcedWidow(er)
Spouse Name

First NameLast Name
Spouse Date of Birth

MonthDayYear
E-mail*
example@example.com
Phone Number*
Residential Address*

Residential Address

Residential Address Line 2

CityState / Province

Postal / Zip Code
Use my Residential Address as my Mailing Address
Mailing Address*

Mailing Address

Mailing Address Line 2

CityState / Province

Postal / Zip Code
Coverage Limits
YesNo
YesNo
Declarations Page

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Rows	Limit
Dwelling
Other Structures
Personal Property
Liability
Medical Payments
Windstorm Coverage Requested?

Underwriting Information
YesNo
Current Homeowner's Insurance Carrier*
YesNo
Please describe
YesNo
Pictures of the Home

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OwnerTenantLessee
YesNo
Please describe other occupants
YesNo
Please describe who it is rented to
Single Family2-4 FamilyCondominium
Year Built*
Year Purchased*
Square Footage of Building*
Square Footage of Porches/Decks*
Number of Stories*
YesNo
Please describe alterations or improvements
Reinforced concreteExposed beamWood rafter (open system for corrugated metal)Wood trussesSteel raftersSteel joists with steel deckingOther
Hurricane clips (secured to bond beam)Re-bar from slab through rafter endNoneOther
Not applicableNot more than 24" apartMore than 24" apartNailed or screwed to each rafter
Aluminum or corrugated metalPaintedStanding seamEnamel finishPlastic tileMembrane CoatingOther
Not applicableNailsScrewsNails & screwsStaplesOther
Not applicableLess than 8"8"12"16"Other
None2'3'4'Other
Reinforced concreteReinforced concrete blockHollow concrete blockBrick or StoneWood studSteel stud3-D PanelOther
Yes, all windowsYes, all windows and all doorsPartial, some windows and/or doors do not have shuttersNo
Roof type steelHinged wood (permanent)Steel panels (portable)Anchor bolts to receive plywoodImpact glassIron grill workAluminum "Miami-style" louversNoneOther
Please explain how exterior openings will be protected in the event of a hurricane
YesNo
Year that it was rewired
Miles to fire department*
Number of fire extinguishers*
YesNo
Number of smoke detectors*
CisternPoolOther
YesNo
YesNo
Pictures, Appraisal, Listing Sheet or Other Helpful Information

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Should be Empty:

Inter-Ocean Insurance Agency

Homeowner's Insurance Quote Form

Customer Information

Coverage Limits

Underwriting Information