3 OR 4 FAMILY HOME 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

Legal Owner Of Building:

Building Location:

City:

State:

Zip code:

Mailing Address (if different from above):

City:

State:

Zip code:

E-mail address:

Home Phone Number:

Cell Phone Number:

REQUIRED INFORMATION

Construction of the Building:	Brick   Frame
If frame, is it attached on both sides?	Yes No
Approximate age of the house?
Number of Apartments?	Select... 1 2 3 4 5 6 7 8 9 or more
Number of Vacant Apartments?	Select... 1 2 3 4 5 6 7 8 9 or more
Does the owner reside in the building?	Yes No
Annual Rents:	$
If the owner lives in one of the apartments do you want us to include coverage for the owners personal contents(furniture, clothing, computers, TV, etc)?	Yes No
If so, approximately what value should we use?	$
Is there a detached garage?	Yes No
Overall Condition of building?	Select... Poor Average Good Excellent
Mortgage?	Yes No
Have there been any claims in the past 4 years?	Yes No
If YES above, please provide details in space below (approx Date of claim(s), description, and amount):

MAJOR RENOVATIONS IN THE PAST 5 YEARS:

Roof?	Yes No
Year Roof Was Renovated:
Electrical?	Yes No
Year Electrical Was Renovated:
Sidewalks?	Yes No
Year Sidewalks Were Renovated:
Boiler?	Yes No
Year Boiler Was Renovated:
Plumbing?	Yes No
Year Plumbing Was Renovated:
Other:

CURRENT COVERAGES

Name of current insurance company:
Renewal date:
Premium:
Current amount of building coverage:	$
Current liability limit:	$
Deductible:	$
Do you have “Special” or “Basic” coverage?	Select... Special Basic
ADDITIONAL INFORMATION

Contact Person:
Contact Preference:	Select... Email Phone
If by phone, best number to call:

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