Dwelling Insurance Quote

Dwelling / Mobile Home Insurance Quote

Fax to Brad Yates 706 675-6622

Owner’s Name____________________ Date of Birth ___________ Social Security # _____________

Mailing Address_____________________________________ Phone______________________

Property Address_____________________________________ City Limits? Yes No

Construction Type: Frame Brick Log Mobile Home Stories: 1 1 ½ 2

If Mobile Home:

Year______ Make_______________ Length____Width____ Serial #(if known) ____________________

Additions- Front ____X____ Back___X____ Underpinning: Vinyl Metal Block

Age of Home_______ Use: Rental (Landlord Package? Yes No) Owner Occupied Vacant

Foundation: Basement Slab Crawl Space Number of Families: _________

Primary Heat Source: Furnace- Gas or Electric Heat Pump Fireplace Space Heaters (Age_____)

Purchase Date:_________ Purchase Price:$ _________Market Value: $____________ Acres: _____

Amount of Insurance: $_________________ Mortgage Amount: $__________________

Year Built:__________ Year Updated: Plumbing_____ Electrical_____ Heating ______ Roof______

Roof Type: Asphalt Wood Metal Slate Other_______________________

Security Devices: ___ None ___ Smoke Detectors ___ Central Fire Alarm ___ Dead Bolts

___ Fire Extinguisher ___ Sprinkler ____ Burglar Alarm

Any Claims? Yes No If Yes, Explain: ________________________________________

Mortgagee Clause: __________________________________________________________________