Dwelling Fire & Secondary Home Quote Submission

Agent's Information

Agency Name*

Agent Name (Contact Person)*

First Last

Agent's Email Address*

Agency Phone Number

Agency Fax Number

Insured's Information

Insured's Name*

First Last

Insured's Social Security Number*

Occupation*

Date of Birth*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Risk Address*

Street Address Address Line 2 City State ZIP Code

Residence Information

Occupancy*

Secondary Home
Tenant Occupied
Vacant

Square Footage*

Year Built*

Year Purchased*

Within City Limits?*

Yes
No

Miles to Fire Department*

Feet to Fire Hydrant*

Primary Responding Fire Department*

Construction Type*

Please describe Other (construction type)

Type of Roof*

Please describe Other (type of roof)

Age of Roof*

Primary Heat Type*

Please note that the primary heating must be central in order to be eligible.

Gas
Electric

Secondary Heat Type*

Updates must have been made within the last 20 years to be eligible

Heating Update*

Plumbing Update*

Electrical Update*

Replacement Cost Information

A Replacement Cost Estimator will be completed at the time of quoting based on the following information

Foundation Type*

Slab
Crawlspace
Basement

% of Basement Finished*

Number of Bathrooms

Builders Grade Custom Semi Custom Designer

Number of Stories*

Please describe*

Attached Garage*

Any Decks, Patios, Balconies ?*

Please check all that apply

Decks
Patios
Balconies
None

Please describe Type and Size:*

Coverage Information

Amount of Dwelling*

Liability Limit*

Medical Payments Limit*

Deductible*

Additional Endorsements Available

Please select those you would like quoted

Earthquake
Water Back-up
Jewelry
Other

Jewelry Limit

Please describe what other endorsements you would like to add*

Protective Devices

Please select those that apply

Dead-bolts, Smoke Detector, Fire Extinguisher
Central Fire Alarm
Central Burglar Alarm

Target Home Premium

Eligibility Information

Who is the Current Carrier*

Expiration Date of Current Policy.*

List all Losses in the Past 5 Years

Click the plus sign at the right to add more losses.

Date	Type

Additional Home Information

Is there a swimming pool on the property?*

Yes
No

Locked Gates?*

Yes
No

Trampoline on Premises?*

Yes
No

Is there a Business Exposure?*

Yes
No

Please describe the type of business exposure*

How many acres is the property on?*

Please list all types of dogs, farm animals and/or unusual exposures

Click the plus sign on the right to add additional animals/exposures.

Any Additional Remarks, Comments, Concerns, or Questions can be added below.

Document Upload

By requesting a quote, you are acknowledging insured's approval to order insurance score and clue.
Upon thorough completion of this form, our target turnaround time for quotes is 24 hours.

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