Is this the

re-building cost. the amount the home is currently covered for. the purchase price of your home.

What Year was your home built?

What is the construction of your home?
Frame  Brick/Stone
Comments on construction (optional)?

If your home is over 30 years old,
when were the following items last renovated?

Plumbing		Heating
Roof		Electric

How many families live in your home? 1   2

Do you live in this house? Yes  No, occupied by tenant

How far do you live from tidal water?
Less than 1000'
More than 1000'
More than 1/2 mile
More than 1 mile

What deductible would you like?
250
500
1000
2500

How much liability coverage would you like?
100,000
300,000
500,000

Do you have any home safety devices?
Central Station Fire Alarm
Central Station Burglar Alarm
Non-Smoker
Dead Bolt Lock on all exterior doors
Smoke Detectors

Would you like Off-Premises Theft Coverage?
(Coverage for your personal items if they are stolen while away from the premises, subject to your deductible)
Yes No (reduces premium)

Do you have any personal items you would like to schedule?
(specifically list to cover)
No Yes

Item	Amount	Replacement Value	Actual Cash Value
Jewelry (watches)
Furs
Cameras
Silver
Fine Arts
Other

How far is the nearest fire hydrant?
within 1000'  over 1000'

How far is the nearest fire station?
within 5 miles  over 5 miles

Are you retired?
No
Yes Please give your date of Birth - Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

How would you like us to give you your quote?

Please e-mail me, my address is
Please call me, my phone # is
Please mail it to my address above