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ABOUT YOUR HOME |
| Year Built: |
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Size (in sq feet):
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| Year Purchased: |
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| Number of Bedrooms: |
Bathrooms
Garages
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Stories: |
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| Structure Coverage: |
$
(also called dwelling coverage) |
| Construction
Type: |
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| Roof Type: |
 |
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Age of Roof: |
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Attached: |
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| Liability Limits: |
$100k
$300k$500k$1,000,000
If you need more
liability insurance, we can quote an umbrella policy from
$500,000 to $5 million. |
|
Personal Property Coverage: |
$
(No Personal Property Coverage is included in
the base price) |
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| Why is the
property vacant: |
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Prior
losses or claims?
(Explain Below )
Woodburning Stove? |
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Swimming
Pool? |
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Electrical:
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Is the dwelling within 500 feet of
native brush, or isolated or inaccessible to fire fighting
equipment?
Yes
No
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Do
you currently have insurance (if yes, with what carrier?)
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What is your current yearly or
monthly premium? |
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Do you have any other information
about your property or comments that you would like to
share? Please place special requests here, such as extra coverage
for special items and information about prior claims. |
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NO COVERAGE IS BOUND, OFFERED, ISSUED
THROUGH THIS ELECTRONIC COMMUNICATION, ALL POLICIES MUST BE
UNDERWRITTEN AND APPROVED BY THE CARRIER. DO NOT CANCEL YOUR CURRENT
INSURANCE. |
|
Copyright 2011 Stratum
Insurance Agency, LLC |