June 25, 2019

Dwelling Quote

The policy will be quoted with $500,000 of Personal Liability coverage. We typically quote a $1,000 Property Deductible, but may also quote higher deductibles in situations where the savings is worth the higher deductible amount.

Policy Holder
Contact Name
Home Address *
Home City *
Home State *
Home Zip
Phone Number
Email *
Full Name of 1st Property Owner *
(If Owned by a Trust or LLC, please list the name of the Trust or LLC)
Full Name of 2nd Property Owner
Date of Birth of 1st Owner?
Social Security Number of 1st Owner?
(Not Required for MD)
Property Location
Address
City
State
Zip
General Information
Is the property currently occupied or vacant? * Occupied  Vacant
Is this a seasonal rental? Yes  No
Dwelling Information
Estimated Replacement Cost
Annual Rental Income *
Square Footage Above Grade
Square Footage of Basement
Year Constructed
How Many Floors Above Grade? 1 Story
1.5 Story
2 Story
Bi-Level
Tri-Level
Other
Type of Construction Wood
Stucco
Masonry
Brick Veneer
Aluminum Siding
Other
Protective Devices Sprinkler System
Central Station Fire Alarm
Central Station Burglar Alarm
Cell Phone & Battery Backup for Alarm System
Home Generator System
Water Leak Detection System
Please provide us with details on any unique features of your dwelling. Things like an elevator, steam shower, wine cellar, media room, historic construction or high-end kitchen.
Renovation Information
If the home is over 25 years old, please provide the following renovation information:
Estimated year the Roof was replaced?
Type of Roof
Estimated year the Furnace was replaced?
Estimated year the electric system was upgraded?
Electrical System Circuit Breakers  Fuses
Claims
List any claims in past 3 years:
  Amount Paid Date of Claim Description
1.
2.
3.
* = Required Field


Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.
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