Donald R. Yert, CEO





Quotation Forms
 
HOMEOWNERS INSURANCE QUOTATION FORM

To help us supply you with the most accurate quote possible, please answer as many questions as you can with the most accurate information available to you.

Information submitted will be held confidential and will be used for quote purposes only. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.



PERSONAL INFORMATION
Your name:  First:      Last:
E-mail address: 
Phone numbers:  Daytime:
Evening:
Fax:
How would you prefer to be contacted 
regarding your quote? 

Phone   Fax   Mail   E-mail

If you would prefer to be contacted by phone, 
please let us know the best time to call. 		 AM PM
Address: 
City: 
State: 
Zip code: 
Social security number:
Occupation:
Date of birth: 
Employer:
STRUCTURAL INFORMATION
What is the style of your home? 
How many stories is your home? 
How many rooms do you have? 

What is the total square footage
of the living area of your home? 
WHAT IS THE STRUCTURE OF THE FOLLOWING
Roof: 
Exterior of your home: 
Foundation: 
Most of the inside walls consist of: 
Most flooring consists of: 
Garage: 
What is the replacement cost of your home: 
HOW MANY OF THE FOLLOWING DO YOU HAVE IN YOUR HOME
Full bathrooms: 
Half bathrooms: 
Fireplaces: 
Decks: 
Enclosed porches: 
Open porches: 
DO YOU HAVE THE FOLLOWING IN YOUR HOME
Swimming pool? 
 Yes No
Trampoline? 
 Yes No
Burglar alarm? 
Sprinkler system? 
Kerosene, wood or oil stove? 
 Yes No
Dog? 
 Yes No
Computer? 
 Yes No 
Livestock?
Yes No
Unusual/exotic pets? 
 Yes No
IS YOUR HOME LOCATED
Within 1000 feet from a fire hydrant? 
 Yes No
Within 5 miles from the firestation? 
 Yes No
On a hillside? 
 Yes No
Close to a body of water or susceptible to flooding? 
 Yes No

GENERAL QUESTIONS

Year home built: 
Number of families living in the home: 
What part of the year is the home occupied? 
Heating and cooling system: 
What term best describes your kitchen? 
Is business conducted on the premises? 
 Yes No
Does anyone in your home smoke? 
 Yes No
Did you experience any loss or claims in the last 5 years? 
 Yes No
PROTECTIVE DEVICES
Smoke detectors?
Yes No
Fire extinguishers?
Yes No
Fire alarm?
Deadbolt locks?
Yes No
ADDITIONAL INFORMATION
Gated community with a security guard: 
 Yes No
Neighborhood watch program: 
 Yes No

Senior citizen discount
(all occupants age 55 or above): 

 Yes No
HOMEOWNERS COVERAGES AND DEDUCTIBLES

Dwelling
(Coverage A - Replacement cost of your home): 

 $
Other structure
(Coverage B - Typically 10% of coverage A): 
 $
Personal property/contents
(Coverage C - Typically 50% of coverage A): 
 $
Loss of use of your home
(Coverage D - Typically 20% of coverage A): 
$
Personal liability: 
 $
Medical payments: 
 $
Desired deductible: 
 $
ADDITIONAL DATA
Quote requested within: 
 24 hrs  48 hrs  72 hrs   120 hrs
Do you want an umbrella quote: 
OPTIONAL QUESTIONS
If you have a collection that is anything of value such as Coins, Stamps, Art etc., specify the value of your collection: 
 $
If you have any furs or jewelry, please specify the approximate value/limits:
$
Do you have any special interests or hobbies that could be  considered a home based business?
Yes No
Do you travel?
Yes No
Do you travel outside of the United States?
Yes No
When you travel, do you bring valuables such as watches, jewelry, or furs with you? 
Yes No
Do you buy things while traveling and want to know that they are immediately insured under your policy?
Yes No
If your home were destroyed, would you want to rebuild it in the same location?
Yes No
Do you have/want backup of sewers and drain coverage?
Yes No