Homeowners Insurance
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Complete the following information if you would like to obtain a Homeowners Flood Insurance quote. Please understand this is not an application. An application will be sent to you if coverage is desired.
All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
Personal Information
What is your name?
What is your business name?
Business Name
What is your address?
What is your telephone number?
What is your fax number?
What is your email address?
Building & Property Information
What is the property address?
Property Street
Property City
Property State
Property Zip
What is the occupancy type?
Occupancy Type
What is the building type?
Building Type
What year was it built?
Year Built
What is the flood map zone number?
Flood Map Zone Number
What is the community flood number?
Community Flood Number
How many Bedrooms?
Number of Bedrooms
How many bathrooms?
Number of Bathrooms
How many fireplaces?
Number of Fireplaces
What date was it purchased?
Date Purchased
Does the residence have a basement?
What is the total square footage of the building?
Total Square Footage of Building
How many units are in the building?
What is the garage description?
Garage Description
How many stories is it?
What is the construction type?
Construction Type
What is the foundation type? Foundation Type
What is the nature of sub-soil?
Nature of Sub-Soil
What is the topography?
What type roof covering?
Is the roof updated?
Roof Updated
Yes No
If yes, what year?
Year Roof Updated
Is there any erosion in the area?
Is there any below ground parking?
Below Ground Parking
Yes No
Is there any soft first story or tuck under parking?
Soft First Story or Tuck Under Parking
Yes No

What is the distance of fire protection?

Is the business in a brush area?
Yes No
If yes, has the brush been cleared by 250 feet from all around the building?
Brush Cleared by 250 Feet
Yes No
Are there smoke detectors at this location?
Smoke Detectors
Yes No
Are there fire extinguishers?
Fire Extinguishers
Yes No
Are there circuit breakers?
Circuit Breakers
Yes No
Is the electrical updated?
Electrical Update
How old is the heating/ air conditioning?
Age of Heating/ Air Conditioning
What is the energy source?
Energy Source
Has the plumbing been updated?
Plumbing Updated
Yes No
If yes, what year was the plumbing updated?
Year Plumbing Update
Is the plumbing copper?
Copper Plumbing
Does the building have interior automatic fire sprinklers?
Automatic Fire Sprinklers
Is there a fire alarm?
Fire Alarm
Has the building been retrofitted or bolted? Retrofitted or Bolted
Claims Information
Where there any losses or claims in the last 5 years?
Losses - Claims
Yes No
If yes, what is the date, amount paid and description of each loss or claim?
Coverage Information
What is the current insurance company?
How much are you paying now?
Amount Current Coverage
What is the building coverage requested?
Building Coverage
What is the other structures coverage requested?
Other Structures Coverage
What is the contents property coverage requested?
Contents Property Coverage
What is the loss of use coverage requested?
Loss of Use Coverage
Are there any questions, comments or additional coverage required?
Questions, Comments or Additional Coverage
Best Time to Contact You
Please let us know the best time to call and discuss your quote.
Or specify other:

Phone 800-931-2922
Fax 412-366-9364
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