Home Proposal Request
Home Information
Full Name *

Address *

City *        State *        Zip Code *        Country *
            
If outside city limits, name of responding Fire Department.        Miles to Dept        

Feet to Hydrant

Social Security #        
Square Footage        
# of Stories
It is:        
I live in or own a:
Owner-occupied  Rented to others
1  2  3  4+ Person Family          Dwelling  Co/op Home  Own a condo
Construction Type
Frame  Brick Over Frame  Solid Masonry  Other (specify)          
Home Extras *
Year Built         
Smoke Detectors         Yes  No
Central Station Burglar         Yes  No
Dead Bolts         Yes  No
Central Station Fire         Yes  No
Fire Extinguisher         Yes  No
Have any of the following systems been updated in last 20 years? *
Roof         Yes  No
Plumbing         Yes  No
Heating         Yes  No
Electrical         Yes  No
Other Questions
Do you have a service contract? *         Yes  No

Type of heat?         

If oil, where is tank stored?  Underground  Above Ground  Basement

Electrical system protected by circuit breakers? *         Yes  No

Do you need special coverage for Jewelry, Furs, Cameras, Fine Arts, etc?*         Yes  
No

If yes, describe item and value:


Have you had any losses to your home or property in the past 3 years? *         
Yes  No

If yes, describe (include date of loss):


Do you own a Swimming Pool? *         Yes  No

If yes, type (ie. Aboveground or Underground):

Fenced  Diving Board/Slide

Do you have a Wood Stove/Pellet Stove? *         Yes  No

Do you own any Animals or Exotic Pets? *         Yes  No

If yes, type (ie. Dog, Cat, Bird, House, Other):

Breed:


Do you own or rent any other property? *         Yes  No

Do you conduct any business out of the home? *         Yes  No


Other Information
Current Insurance Company        Current Policy Expires*        Current Premium



If Renting: Number of apartments in your building          
Dwelling or Building Coverage Limit $         
Value of Personal Property or Contents         

Deductible         $250  $500  $1,000

Medical Payment         $1,000  $5,000

Personal Liability Limit         $100,000  $300,000  $500,000  $1,000,000


Fair Credit Reporting Act Notice: We are required to inform you that as part of our
underwriting procedure, a consumer report may be requested. Additionally,
subsequent consumer reports may be requested on renewal or as an update on
your insurance application. Upon your written request, you will be informed
whether or not a consumer report was requested, and if so, the name and address
of the consumer reporting agency to whom the request was made.