Homeowner Insurance

Personal Contact Data:

Name
Physical Address 1
Address 2
City
State
Zip
Date of Birth	01/01/1990
Social Security No.	111-22-3333
Home Phone	704-111-2222
Work Phone	704-111-2222
E-mail
Spouses Name
Social Security No.	111-22-3333
Fire District
Best Time to Contact

Home Insurance Survey:

1.  Do you have homeowner insurance now? Yes  No
      If yes, which company? 

 

2.  How much do you currently pay? 

 

3.  When does your policy renew:    01/01/1990

4.  How often do you pay your insurance?  Monthly Quarterly Semi-Annual Annual

Home Information:

1. Current coverage amount on dwelling: 

2. Current coverage amount on contents: 

3. Replacement cost type:  Home Contents Both

4. Protective devices: 

        Smoke Detectors Yes  No
        Dead Bolts  Yes  No
        Burglar Alarms   Yes  No

5. Pool Yes  No (Fenced Yes  No)

6. Type of Construction::  Brick / Stone Siding / Frame

7. Year Built:  1998

8. Type of heating system: 

9. Any Woodstoves, Fireplace inserts, ect?  Yes  No   Which?

Coverage Information:

1. Liability Limit:  100K 300K 500K

2. Medical Payments: 1000 2000 5000

3. Deductible:  250 500 1,000