Home Insurance Application

Thank you for visiting our home insurance application page.
Please complete the form as best you can. We will contact you in the next two business days.
Please note: Completing this application is for your convenience and does NOT establish insurance coverage!

Contact information:
First Name / M.I.:
Last Name:
Mailing Address:
City:
State:	Select... AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
ZIP Code:
Daytime Phone #:
Evening Phone #:
E-mail:
Current policy expiration date:	MM / DD / YYYY

Location information:
Is the dwelling located within:
1000 feet of a fire hydrant?	Yes No
5 road miles of a responding fire station?	Yes No
Is the home in a development?	Yes No
Check here if this dwelling is a Condominium

Occupancy and Structural information:
Occupancy:
Number of families	Select... 0 1 2 3 4 or more
Who lives in the dwelling?	Select... Owner Tenant(s) Owner & Tenant(s) Under construction Vacant
What part of the year is the dwelling occupied?	Select... Year-round Occasional Seasonal / Vacation None (Vacant) Snow-bird
Is business conducted on the premises?	Yes No
Environmental:
Is your area prone to landslides and/or sinkholes?	Yes No
Do you have a dog?	Yes No, If Yes, What Breed?
Do you have any livestock or exotic pets?	Yes No
Do you have a swimming pool on the premises?	Yes No
Do you have a wood, oil or kerosene stove?	Yes No
Structural:
Year built     (Please enter a four-digit date)	YYYY
Style of dwelling	Select... Adobe Bungalow Cape Cod Colonial Contemporary Dome Earth home Envelope Log home Mediterranean Queen Anne Ranch Raised Ranch/Bi-level Split level/Tri-level Steel frame Timber frame Townhouse/Rowhouse center unit Townhouse/Rowhouse end unit Victorian
Number of stories	Select... 1 story 1 1/2 stories 2 stories 2 1/2 stories 3 stories 4 or more stories Bi-level Tri-level
Is your home accessible to emergency equipment?	Yes No

Total living area (approximate square feet) Exclude porches, basements, decks, breezeways, and garages (but include built-in or basement garages).
Primary exterior wall type	Select... Adobe Aluminum/Vinyl siding Asphalt Brick veneer Cement fiber Clapboard Concrete block Log siding Logs Mineral fiber Painted masonry Precast concrete Precast stone Slump block Split block Solid brick Solid stone Stone veneer Stucco on frame Stucco on masonry Wood shakes Wood siding
Roof covering	Select... Architectural shingles Asphalt shingles/Fiberglass shingles Built-up/Tar and gravel Clay tile Concrete tile Corrugated steel Mineral fiber shakes Mission Tile Rock roof Roll roofing Rubber roof Slate Tin Wood fiber shingles Wood shake
Is there a garage in your home (what # of cars)?	Yes No
How many full bathrooms are in your house?
How many half bathrooms are in your house?

Supplemental information:
How many losses or claims have you experienced in the last 5 years?	Select... None 1 2 3 4 5 or more
Replacement Cost: Please enter your home's replacement cost. This is the cost of rebuilding your home at today's prices, not the sale price.
Enter the replacement cost for your home in the field to the right. Tip: You may want to use the amount listed under "Coverage A" on your current homeowners policy.	$
Description of Loses
If your house is more than 30 years old, how long has it been since the roof was replaced	years

Discount information:
Protective devices:
Fire extinguishers	Yes No
Smoke detectors	Yes No
Fire alarm type	Select... None Local Central Fire station
Deadbolt locks	Yes No
Burglar alarm type	Select... None Local Central Police station
Deductible and Coverage Amounts:
Policy deductible	Select... $250 $500 $1,000 $2,500 $5,000
Coverage A: Dwelling structure replacement	$
Coverage B: Other structure replacement Typical coverage limit: 10% of Coverage A ($10,000) If left blank,will be based on %'s you listed	$
Coverage C: Contents or personal property Typical coverage limit: 50% of Coverage A ($50,000) If left blank,will be based on %'s you listed	$
Coverage D: Additional living expenses Typical coverage limit: 20% of Coverage A ($20,000) If left blank,will be based on %'s you listed	$
Extra Coverages on Current Policy	$
Personal liability	Select... $100,000 $200,000 $300,000 $400,000 $500,000 $750,000 $1,000,000
Medical payments	Select... $1,000 $2,000 $3,000 $4,000 $5,000 $7,500 $10,000 $25,000

Extended dwelling replacement cost coverage	Yes No
Extended contents replacement coverage	Yes No