Application
I. Client Account Information
Name: ______Home/Mobile phone: ______Work phone: ______
Mailing Address: ______City______State______Zip Code ______County: ______
Birth Date: ______/______/______
Email: ______Occupation: ______Occupation Detail: ______
Effective Date:______Prior Carrier: ______
II. Homeowners Information
Number of residences ______(please print additional copies for each residence) Year built: ______
Number of rental properties ______(please print additional copies for each property)
Location Address (street, city, zip code: ______Building Value: $______Contents Value:$______
Square Footage: ______Primary Liability: $______Year Built: ______# of Mortgages: ______Mortgagee:______
Stories above ground (include 1/2 stories) ______Construction (check one) Frame/stucco Masonry Veneer Masonry Other: ______
Roof Type (check one) Asphalt/Shingle Wood Shake Tar/Gravel Slate/Clay Concrete Tile Other: ______Age of roof: ______
Foundation type (check one) Basement Crawl Space Slab Is the house bolted to the foundation? Yes No
Distance to Fire station: ______Distance within 1000’ of Fire hydrant: ______Central station fire/burglar alarm: ______
Interior residential sprinkler system: Yes No 24-Hour Security: Yes No Caretaker: Yes No Signal Community: Yes No Water Flow Alarm: Yes No
Temperature Monitor: Yes No Back-Up Generator: Yes No Gas Leak Detector: Yes No Seismic Shut -Off Valve: Yes No Lightning Protection: Yes No
Water Leak Detection: Yes No Water Leak Detection Alarm: Yes No
Has dwelling been retrofitted? Yes No If yes, when? ______
Home located in a gated community: Yes No If yes, is there a Patrol Service: Yes No Number of domestic employees: ______
Have there been any claims at the property within the past five years? If so, please explain: ______
Deductible: $______Earthquake: ______Losses: ______Valuable Articles: ______
Scheduled Items Total Value Estimated # of Items Description & Additional Comments
Jewelry $ ______
Fine Art $ ______
Antiques & Fine Furniture $ ______
Silverware $ ______
Musical Instruments $ ______
Cameras $ ______
Wine $ ______Where is it stored? ______
Furs $ ______
III. Driver Information
Driver's Name License # State Licensed Since Gender Date of Birth Annual Miles Tickets/ Claims in past 5 years?
1.) ______/___/______
Street: ______City: ______State: ______Zip Code: ______County: ______
Phone: ______Occupation/Industry: ______Occupation Detail: ______
Driver's Name License # State Licensed Since Gender Date of Birth Annual Miles Tickets/ Claims in past 5 years?
2.) ______/___/______
Street: ______City: ______State: ______Zip Code: ______County: ______
Phone: ______Occupation/Industry: ______Occupation Detail: ______
Driver's Name License # State Licensed Since Gender Date of Birth Annual Miles Tickets/ Claims in past 5 years?
3.) ______/___/______
Street: ______City: ______State: ______Zip Code: ______County: ______
Phone: ______Occupation/Industry: ______Occupation Detail: ______
Driver's Name License # State Licensed Since Gender Date of Birth Annual Miles Tickets/ Claims in past 5 years?
4.) ______/___/______
Street: ______City: ______State: ______Zip Code: ______County: ______
Phone: ______Occupation/Industry: ______Occupation Detail: ______
IV. Vehicle Information
VEHICLE # 1 Year: ______Make: ______Model: ______VIN #: ______State Registered: ____
Prior Carrier: ______Effective Date: _____/_____/______Road Service Coverage: ______
Full Window Glass: ______Comp Deductible: $______Collision Deductible: $______Liability Limit: $______
UM/UIM Option ______UMPD: ______Med Pay: ______Excess Limit: ______
VEHICLE # 2 Year: ______Make: ______Model: ______VIN #: ______State Registered: ____
Prior Carrier: ______Effective Date: _____/_____/______Road Service Coverage: ______
Full Window Glass: ______Comp Deductible: $______Collision Deductible: $______Liability Limit: $______
UM/UIM Option ______UMPD: ______Med Pay: ______Excess Limit: ______
VEHICLE # 3 Year: ______Make: ______Model: ______VIN #: ______State Registered: ____
Prior Carrier: ______Effective Date: _____/_____/______Road Service Coverage: ______
Full Window Glass: ______Comp Deductible: $______Collision Deductible: $______Liability Limit: $______
UM/UIM Option ______UMPD: ______Med Pay: ______Excess Limit: ______
VEHICLE # 4 Year: ______Make: ______Model: ______VIN #: ______State Registered: ____
Prior Carrier: ______Effective Date: _____/_____/______Road Service Coverage: ______
Full Window Glass: ______Comp Deductible: $______Collision Deductible: $______Liability Limit: $______
UM/UIM Option ______UMPD: ______Med Pay: ______Excess Limit: ______
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