Agent Information:
Agent Name:
Agency Name:
Agent Email:	(A copy of the quote will be sent to this address)
Agent Phone:

Insured Information:
Insured Name:
Date of Birth:	//
Mailing Address:
Mailing City:
Mailing State:
Mailing Zip Code:
If the insured lives out of state, is there a management company used?	--choose-- N/A Yes No

Add Another Location

Dwelling Continued:
Are the Dwellings in Good Condition?	Yes No
Do the Dwellings have any Existing Damage?	Yes No
Are the Dwellings Undergoing any Renovation or Construction?	Yes No
Are there horses on any of the premises? (If yes, quote will be rejected)	Yes No
Do any of the Dwellings have a Wood Burning Stove?	Yes No
If yes to the above, is it the Primary Heat Source?	n/a Yes No
Do any of the Dwellings have Polybutylene or Qwest Plumbing?*	Yes No
	* Polybutylene plumbing is flexible gray plastic piping that is put together with a crimp connector.
Are there Business Pursuits on any of the Premises?	Yes No
Are any of the Dwellings located on more than 2 acres of land?	Yes No
Are there any unfenced swimming pools or bodies of water on any of the premises?	Yes No
Are any of the Dwellings Located Within 1,000 Feet of the Atlantic Ocean?	Yes No
Have all roofs been replaced within the last 20 years (15 for Doublewides)?	Yes No
Have there been any Repossessions in the last 3 years?	Yes No

Mortgage Payments:
Are Mortgage Payments Current?	Yes No

Insurance History:
Are any of the Dwellings a new Purchase?	Yes No
Was it a foreclosed property when purchased?	--choose-- Yes No
If yes to the above, what was the purchase price?
Has there been any Prior Insurance on this Account?	Yes No
Please input name of Prior Carrier:
Expiration Date of Previous/Current Insurance?:
Was Policy Terminated at Companies' Request?	Yes No
Has there been a Lapse of Coverage over 30 Days?	Yes No
What was the Reason for Termination?	Coverage Has Never Been Cancelled or Terminated Company no Longer Writing in that Area Nonpayment of Premium Failure to Comply with Inspection Recommendations Loss History Credit History Unacceptable Animal on Premises Condition of Dwelling Insured Shopping Other

Loss History:
Any Open Claims?	Yes No
Number of Losses in the Last Three Years:

	Date	Type of Loss	Details	Amount Paid
1)		Fire Water Damage - Weather Related Water Damage - Non-weather Related Wind Damage Hail Damage Theft Physical Damage - All Other Liability		$
2)		Fire Water Damage - Weather Related Water Damage - Non-weather Related Wind Damage Hail Damage Theft Physical Damage - All Other Liability		$
3)		Fire Water Damage - Weather Related Water Damage - Non-weather Related Wind Damage Hail Damage Theft Physical Damage - All Other Liability		$

Other Coverages:
Limit of Liability:	$0 $25,000 $50,000 $100,000 $300,000
Loss of Rents:	N/A 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000 11000 12000 13000 14000 15000 16000 17000 18000 19000 20000
Owner's Contents Coverage:	1000 2000 3000 4000 5000 6000 7000 8000 9000 10000
Owner's Contents Burglary Coverage	N/A $1,000 $2,000
	Burglary Coverage cannot be applied unless a value is chosen for Owner's Contents Coverage above.
Satellite Dish Coverage
	The maximum satellite coverage available online is $3000.

Credits:
Deadbolts, Smoke Alarms, Fire Extinguishers?	--select-- Yes No
Central Station Fire, Smoke and Burglar Alarms?	--select-- Yes No
Higher Deductible?	Default $2,500

Applicant:
Please choose one of the following to describe insured's credit history:	Good Fair Poor
Has the Applicant had any Conviction of Arson or Fraud Related to any loss on Property or Insurance?	Yes No
Has there been a Bankruptcy Within the Last Year?	Yes No
Has there been any Foreclosure within the last Five Years?	Yes No
Any past due Child Support?	Yes No

Financing:
Would you like a Finance Quote?	--choose-- Yes No
Would you like a Finance Quote?	--choose-- Yes No

Additional Comments
Any Additional Comments: