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

Dwelling:
Protection Class:*
	* If you do not choose a protection class, your quote is not valid and cannot be honored by Commonwealth Underwriters.
Is Dwelling Owner Occupied?
Type of Dwelling:
Is this a Single Family Residence?
Year Built:*
	* Please note: Dwellings built before 1985 must have had updates within the last 20 years to qualify for this program. Details of updates will be required on application. (Roof, Electrical, Plumbing, and Heating)
Is Dwelling in Good Condition?
Does Dwelling Have any Existing Damage?
Is Dwelling Undergoing any Renovation or Construction?
Type of Construction:
Are there horses on premises? (If yes, quote will become submission)
Is there a Wood Burning Stove?
If yes, is it the Primary Heat Source?
Is there any Polybutylene or Qwest Plumbing?*
	* Polybutylene plumbing is flexible gray plastic piping that is put together with a crimp connector.
Any Business Pursuits on the Premises?
Is the dwelling located on more than 2 acres of land?
Any unfenced swimming pool or body of water on the premises?
Have there been any Repossessions in the last 3 years?

Dwelling Cont'd
Is the Dwelling Located Within 1,000 Feet of the Atlantic Ocean?

Dwelling Cont'd
Has roof been replaced within the last 20 years?

Applicant:
Please choose one of the following to describe insured's credit history:
Has the Applicant had any Conviction of Arson or Fraud Related to any loss on Property or Insurance?
Has there been a Bankruptcy Within the Last Year?
Has there been any Foreclosure within the last Five Years?
Any past due Child Support?

Mortgage Payments:
Are Mortgage Payments Current?

Insurance History:
Is this a new Purchase?
Has there been any Prior Insurance on this Account?
Was this a foreclosed property when purchased?
If yes to the above, what was the purchase price?
Please input name of Prior Carrier:
Expiration Date of Previous/Current Insurance?:
Was Policy Terminated at Companies' Request?
Has there been a Lapse of Coverage over 30 Days?
What was the Reason for Termination?

Loss History:

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

Coverages:
Value of Dwelling?*	$
	*Do not input commas
Previous Wind/Hail Deductible?

Optional Coverages:
Ordinance or Law Coverage
Water Backup Coverage:
Replacement Cost Personal Property
Extended Replacement Cost - Dwelling
Special Computer Coverage
Identity Fraud Expense Coverage

Credits:
Deadbolts, Smoke Alarms, Fire Extinguishers?
Central Station Fire and Smoke Alarms?
Central Station Burglar Alarm?
Higher Deductible?

Additional Comments
Any Additional Comments: