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Homeowner's Insurance Application
This application has been designed to gather all the information we need to prepare a complete insurance proposal for you, not just a premium "estimate".
Please Note: All fields are required
CONTACT INFORMATION
First Name
Phone Number (daytime)
ex: xxx-xxx-xxxx
Middle Initial
Phone number (evening)
ex: xxx-xxx-xxxx
Last Name
Email Address of person requesting quote
Address
Name of your Realtor, if any
City
State
Zip
 
PROPERTY INFORMATION
Property Street
Zip
City
County
State
Township, Borough or Municipality
Insured's previous address
 
APPLICANTS
  Name Birthdate (month/day/year) Social Security Number
1.
2.
3.
4.
 
QUESTIONS
What is the effective date?
Do you have a swimming pool at this home?
If you have a pool, is there a fence around it?
Is this home within 1000 feet of a fire hydrant?
Do you have a wood, kerosene or oil stove in this home?
How far to the nearest Fire Department
Is there a trampoline at your home?
Is this home your main residence or a second home?
Does this home have a flat roof?
Describe the construction of your exterior walls
Is there a finished attic?
Number of Stories
Is there a walk-out basement?
What year was your home built?
Is there a finished basement?
If older than 20 years, when were the following updated:
Plumbing:
Heating:
Electrical:
Roof:
Is there a deck?
What is the approximate lot size?
If there is a deck, how many square feet is it?
How many square feet is this house?
How many fireplaces?
Does only one family live in this home?
How many bathrooms?
Describe the style of your home?
Style of garage?
What is the amount of coverage on your home that you would like?
Garage holds how many cars?
What is the amount of personal liability coverage that you would like?
Is the home air conditioned?
How much medical coverage (Good Samaritan) would you like?
If air conditioned, type of system?
What property deductible would you like on this home?
Does the home have an alarm system?
Do you operate a business from within your home?
On your existing home, how many claims have you reported in the last five years?
 Name of Mortgage Company
Do pets or exotic animals live in this home with you?
Address of Mortgage Company
If yes, what type of pet?
 
Insurance products are not available in every state. Insurance & Bonds, Inc. is not licensed in every state. Restrictions may apply. Nothing on this application constitutes a policy, binder or agreement to provide coverage. All applicants must meet underwriting requirements.
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