Homeowners

Homeowners Online Quote - HO-3

Quote instantly below or call 800-396-6226 x600 for an instant phone quote

Agent Information

Agency Name

-OR-

Agent Lookup Code

Agent Names

Agent Name (first and last)

Phone:

Fax:

Agent Email:

Agency's Mailing Address

Agency City

Agency State

Agency Zip

Insured Information

Insured Name:

Insured Email:

Insured Phone Number:

Date of Birth:

Occupation:

Employer:

Is there an additional resident or spouse?

Street Address of Residence to be Insured:

Residence City:

Residence State:

Residence Zip

Is the Mailing Address the same as the Street Address?

Mailing Address

Mailing City

Mailing State

Mailing Zip

Is this a corporation?

Is this a trust?

Trustee Mailing State:

Effective Date

Proposed Effective Date:

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 visible to neighbors?

Is dwelling within 1000 feet of an adequate water source to fight a fire?

Is response time of primary responding fire department less than 15 minutes?

Is dwelling easily accessible year-round?

Is this a Single Family Residence?

Is Dwelling Owner Occupied?

Is this a manufactured home?

Type of Dwelling:

Is dwelling rented to others?

Number of Stories:

Year Built:*

Dwelling Area (sq. footage):

* Please note: Dwellings built before 2002 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:

* Condos cannot be quoted online, please contact our Personal Lines dept. at 800-396-6226 x600 for assistance.

Type of Foundation:

* Please provide an explanation in the Additional Comments section at the bottom of the page

Does the dwelling have central heating regularly serviced by a licensed professional?

Is there a Wood Burning Stove?

Is the wood burning stove 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.

Year of last water heater replacement?

Type of roofing material:

Is the roof flat?

Year of last roof replacement?

Type of siding material:

Is the dwelling located on more than 2 acres of land?

Is the dwelling located on more than 10 acres of land?

Any unfenced swimming pool or body of water on the premises?

Is the Dwelling Located Within 1,000 Feet of the Ocean, Bay or Sound?

Number of Golf Carts?

Any animals with a bite history on the premises?

Are there horses on premises? (If yes, quote will become submission)

Any Business Pursuits on the Premises?

Have there been any Repossessions in the last 3 years?

Update Years

Electricity

Plumbling

Heating / AC

Is the electrical service fully updated to 100 Amp or greater, including U/L approved copper wiring, and circuit breakers of proper amperage in good condition? (Click if Yes)

Does the home have any fuse boxes? (Click if Yes)

Does the home have any knob and tube wiring? (Click if Yes)

Does the home have any aluminum wiring? (Click if Yes)

Does the home have any lead plumbing? (Click if Yes)

Loss Payee/Mortgagee

Is there a loss payee or mortgagee?

Loss Payee State:

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?

Year Purchased?

Was this a foreclosed property when purchased?

What was the purchase price?

Has there been any Prior Insurance on this Account?

* Please provide an explanation in the Additional Comments section at the bottom of the page

Loss History

Any Open Claims?

Number of Losses in the Last Five Years:

#

Date (MM)

Date (YYYY)

Loss Type

Details

Paid Out($)

1

2

3

4

5

Coverages

Replacement Cost - Coverage A

Coverage B - Other Structures - Percentage of Coverage A

Coverage C - Contents - Percentage of Coverage A

Coverage D - Loss of Use - Percentage of Coverage A

Liability

Limit of Liability:

Increased Medical Pay:

Other Coverages

Home Systems Protection Coverage:

* Please note: Dwellings with Coverage A > $800,000 do not qualify for this optional coverage

Service Line Coverage:

Identity Theft Recovery:

Water Backup Coverage:

Replacement Cost Personal Property

Extended Replacement Cost - Dwelling

Special Computer Coverage

Credits

Deadbolts, Smoke Alarms, Fire Extinguishers?

Central Station Fire and Smoke Alarms?

Central Station Burglar Alarm?

Higher Deductible?

Commission

What commission would you like for this account?

Additional Comments

Any Additional Comments

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If you are seeing this message then you do not meet these requirements.

For higher limits or coverage options not listed, please contact ourPersonal Lines department, Ext 600.

Any questions or problems with the form? Please contact ourPersonal Lines department

Only Commonwealth Underwriters, Ltd. has binding authority. Coverage will not be bound until application has been received, reviewed, and accepted by Commonwealth Underwriters, Ltd.

Homeowners Online Quote - HO-3

Agent Information

Insured Information

Effective Date

Dwelling

Update Years

Loss Payee/Mortgagee

Applicant

Mortgage Payments

Insurance History

* Please provide an explanation in the Additional Comments section at the bottom of the page

Loss History

#

Date (MM)

Date (YYYY)

Loss Type

Details

Paid Out($)

1

2

3

4

5

Coverages

Liability

Other Coverages

Credits

Commission

Additional Comments

Submission Failure