Home Quote Sheet
Agent:
Quote Date:
Quote Time:
Reason for Policy:
Effective Date:
Other Polices:
How did you hear about us:
First Named Insured:
Last,
Co-Applicant:
Last,
First
First
Middle
Middle
DOB:
Suffix
SSN:
Employer:
Occupation:
Employer:
Cell Phone:
Work Phone:
Email:
Preferred Contact:
Total Number in Home:
Address:
Mail:
SSN:
Occupation:
Co-Applicant Education:
Home Phone:
DOB:
Suffix
First Named Insured Education:
Payment Method: EFT or Mail
#
#
Street
City
Street
State
City
Prior Carrier:
Coverage B:
Coverage E:
Coverage F:
Length of Continuous Coverage:
Cost Coverage: Actual Cash Value
N
Issue Date:
Coverage C:
Deductible:
Any Cancels/ Lapses: Y N
Replacement Cost
Own
Other Mobile Home
Inspection Date:
Zip
Current: Y
Coverage A:
Rent
Zip
State
How Long in Home:
Expiration Date:
Coverage D:
Perils: Basic Broad Open
Days Lapsed:
Reason For Lapse:
Misc. Endorsements:
Claims History for Past 5 Years
DATE
TYPE
Lien Holder
DESCRIPTION
Mortgages
Lien Holder Address
AMOUNT
Loan Number
Year Built:
Number of Stories:
Year Renovated:
Style:
Update Year: Plumbing:
Construction Type:
Fire District:
Total Living Area:
Roof:
Electricity:
Under Construction: Y N Usage:
Protection Class:
Occupancy:
Distance to: Fire Station:
Foundation
%
Basement
%
Exterior Walls
%
Roof Type
%
Floor Finish
%
Ceiling Finish
%
Type
Basic Builder’s Semi Custom Custom
Grade
Heat:
Designer
Fire Hydrant:
Partition Walls
AC & Heating Type %
Garage
# of Cars
Attached
Detached
Built-in
Carport
Kitchen
Full Bath
¾ Bath
Half Bath
Elaborate Roof: Yes No Cathedral Ceiling %:
Exterior
Features
#
Interior
Features
Fireplace
#
Protective
Devices
#
#
Attached
Structures
A/C or Heat
Specialties
#
#
%
Detached
Structures
Conveying
Systems
#
#
Additional Structures To Be Insured:
Year SQ. FT
Value
Usage
Animals:
Contents & Value
Any Attacks?: Y
Livestock
What Kind
N
Date of Attack:
How Many
Claim Amount:
Pets
Type
Breed
Any Acreage/Farming: Y
N
Number of Acres:
Usage:
Incidental Business:
N
Annual Revenue:
Description:
Y
Watercraft Liability:
Year
Type
Max Horsepower
Coverage Options:
Perils: Basic Broad Open
Scheduled Items:
Item Description
Requested Endorsements:
Cost Valuation:
Value
Length
Replacement Cost
Item Description
Value
Actual Cash Value
Item Description
Value
Total Cost Evaluator Options:
House Style:
Ranch, Cape Cod, Colonial, Bi-Level, Split Level, Back Split, Bungalow, Condo/Co-op, Contemporary, Cottage, Federal Colonial, Mediterranean, Ornate Victorian, Queen Anne, Raised
Ranch, Rambler, Row House Center, Row House End, Southwest Adobe, Split Foyer, Substandard, Town House Center, Town House End, Tri-Level, Victorian, Bi-Level Row End, BiLevel Row Center, Tri-Level Row End, Tri-Level Row Center, 1 Story, 1.5 Story, 2 Story, 2.5 Story, 3 Story
Exterior Walls:
Brick: Solid, Custom Solid Stucco: On Frame, On Masonry, With Adobe On Frame: Brick, Custom Brick, Stone, Custom Stone, EIFS
Shingles: Pine, Cement Fiber
On Masonry: Brick, Wood Siding, Cement Fiber (Shingle/Siding), Stone, Custom Stone, Steel, Vinyl, Aluminum, Clapboard, Hardboard, New England Shingle
Misc: Greenhouse Wall, Solid Logs, Adobe, Window Wall, Slump Block, Victorian Scalloped Shake Stone: Solid 12”, Solid 12” Custom, Solid 18” Custom, Solid 24”, Solid 24” Custom
Siding: Aluminum, Logs, Vinyl, Wood, T-111, Redwood Clapboard, Hardboard, Plywood, Barn Plank, Custom Logs, Steel, Cement Fiber Solid 18”
Concrete: Painted Block, Decorative Painted Block, Poured in Place 7-10”, Poured in Place 4-6” Breakaway Wall: Unreinforced Masonry, Lattice On Frame
Roof:
Shingles: Asphalt/Fiberglass (composite), Wood, Pine, Architectural, Aggregate Finish Steel, Synthetic/Rubber Tile: Clay, Concrete, Mission, Spanish
Misc: Built-up Tar/Gravel, Tin, Rubber, Slate, Steel, Copper, Translucent Fiberglass Panel, Plexiglass, Vinyl, Hail Proof, Single Ply Rolled Roof, Foam , Steel Standing Seam
Photovoltic: Shingles, Tiles Aluminum: Corrugated, Shingle, Standing Seam Shakes: Wood, Victorian Scalloped
Floor Finish:
Tile: Mural, Terrazzo, Ceramic, Marble, Imported Ceramic, Porcelain, Travertine
Wood: Hardwood, Plywood, Laminated Wood, Engineered Wood
Carpet: Acrylic/Nylon, Wool/Berber, Over Hardwood, Wool/Berber Over Hardwood, Custom Acrylic Over Hardwood, Custom Acrylic/Nylon
Misc: Parquet, Vinyl, Slate, Plank, Brick, Flagstone, Granite, Stone, Cork, Laminated Bamboo Plank, Bamboo, Rubber, Textured Concrete
Wall Finish:
Paint, Sponge Coat, Vinyl Wallpaper, Sheet Paneling, Ceramic Tile, Brick Facing, Stone Facing, Marble Tile, Knotty Pine Paneling, Grass Cloth Wallpaper, Millwork, Mirrors, Terrazzo,
Carpet, Corkboard, Pegboard, Tongue & Groove Paneling, Marble Paint, Foil Mirrors, Solid Wood Paneling
Ceiling Finish:
Drywall, Plaster, Acoustical Tile, Wood, Horsehair Plaster, Tongue & Groove, Textured Drywall, Millwork, Mirrors, Tin, Plank, Textured Plaster, Plywood Only, Carpet, Stucco Finish,
Recessed Lighting, Marble, Metal, Decorative Wood Beams, Ornate Textured Drywall, Recessed Lighting, Acoustical Textured Spray
Partition/Interior Walls:
Plaster, Studs Only, Horsehair Plaster, Drywall, Solid Brick, Textured Drywall, Solid Stone, Stone & Block, Textured Plaster, Block, Block & Brick, Adobe, Glass Block, Ornate Textured
Drywall
Exterior Features:
Window: Atrium, Bay, Bow, Picture, Greenhouse, Small Stained Glass, Large Stained Glass Skylights: Large, Small, Large Solar Tube, Small Solar Tube Shutters: Storm, Storm Proof
Misc: Solar Panels, Photovoltic System, Hillside Skirting
Interior Features:
Hot Tub, Wet Bar, French Doors, Jacuzzi, Wood Spiral Staircase, Metal Spiral Staircase, Vanity (Custom), Finished Attic, Suana, Freestanding Wine Captain, Under counter Wine
Captain, Pre-Fab Home Theater Room, Low Voltage Lighting
Temperature Regulation Systems:
Heating: Average Cost System, Gas, Oil, Electric, Additional Furnace, Forced Air Gas, Hot Water Gas, Forced Air Oil, Hot Water Propane, Oil Hot Water Radiator, Heat Pump, Radiant
Floor, Electrical Thermal Storage, Geothermal Open/Closed
Fireplaces & Stoves: Freestanding Wood Stove, Single/Double/Triple Fireplace, Zero Clearance Fireplace, Pre-Fab Fireplace, Kiva Gas Fireplace, Wood Pellet Stove, Wood Burning
Masonry Heater, Direct Fireplace
Air Conditioning: Average Cost Central Air, Same Ducts Central Air, Separate Ducts Central Air, Evaporative Cooler, Whole House Fan, Heat Pump HE, Central Air He Same Duct,
Central Air HE Separate Ducts
Heating & A/C Specialties: Average Ceiling Fan, Custom Ceiling Fan, Deluxe Ceiling Fan, Air Exchange Unit, Outdoor Wood Furnace, Humidifier Furnace
Foundation:
Slab, Crawl Space, Basement, Finished Basement, Pier Foundation, Hillside Foundation
Protective Systems:
Central Burglar Alarm, Central Fire Alarm, Lighting System, Surveillance, Interior Sprinkler, Wireless Security System, Intercom System
Misc. Systems:
Lift Chair, Wheel Chair, Elevator, Central Vacuum, Central Stereo