Name 1
DOB
SS#
Name 2
Address
City
State
Zip Code
Address 2 if less than 3 years (address, city, state, and zip)
Home Phone
Work / Other Phone
Are you:
What is the total square footage of the home we are going to insure?
Number of Stories
Central Heating & Air
Fireplace
Deck or Patio?
How many baths?
How many half baths?
Do you have a garage or carport?
Is it:
Is the home mostly:
What year was the home built?
Was the home purchased new?
If the home is over 15 years old has it been rennovated?
If rennovated, select what
Do you have
Who is your current insurance company?
How long have you been with them?
Current Premium
Which deductible are you insterested in?
Have you had any property insurance losses in the past 5 years?
If so, when?
What type of loss?
Do you have any speciial coverage needs such as jewelry?
If so, amount
We can save you additional money by insuring your autos, would you like a proposal?
Home Inventory Value Worksheet