Dwelling Fire Insurance Quote Request Form

First Name

Required

Last Name

Required

What is the full name of the person who referred you to us?

Required

Best contact phone number

Required

E-Mail Address

Required

Best method of contact

Required

Full legal mailing address

Required

ZIP / Postal Code

Required

What is your date of birth?

Required

If married, please list your spouse's full legal name and date of birth. (If single, answer "N/A".)

Required

Is there anyone else listed on the deed? If so, please indicate name, relationship to you and date of birth.

Required

Full legal property/location address

Required

Number of Units

Required

What is the closing date and/or the purchase date?

Required

/

If not a new purchase, what is the home currently insured for?

Optional

What year was your home built?

Required

Do you have planned renovations on the rental home? If so, please provide details

Required

What is the estimated market value of the home AFTER you have completed renovations? (If you answered "no" to the above question, please input current market value.)

Required

What is the style of your home?

Required

Bi-level2 story
RanchTri-level
1.5 storyOther

What is the occupancy type? (Is the home currently rented, or is it vacant? If vacant, please advise when you expect it to be rented out.)

Required

What is the square footage of the home? (Not including the basement or built-in garage)

Required

Is it built on basement, slab or crawlspace? What percentage?

Required

If there is a basement, what % is finished? Is it a walk-out or daylight?

Required

What is the home's construction type?

Required

Frame
Brick
Stone
Other

What type of siding is on the home?

Required

Vinyl
Aluminum
Brick/Brick Veener
Other

What is the garage type and number of stalls? (Ex: Attached 2-stall, Detached 3-stall, built-in)

Required

Please describe all home claims made in the last 5 years? Please include date and reason for claim. (Type NA if not applicable)

Required

Do you have any outbuildings, such as a shed or barn? Please list size, value and condition (Type NA if not applicable).

Required

What group or association are you or your spouse a member of? (Check all that apply)

Optional

Credit Union
AARP
Alumni
None
Other

Do you and your spouse have a college degree? If so, what level of degree and where from? (Ex: Bachelors from University of Michigan)

Required

Please advise the year each of the following four categories were updated: Roof, Electrical/Wiring Box, Plumbing, HVAC/ furnace (to the best of your knowledge)

Required

Does the home have buss fuses, or a Breaker Box? If a breaker box, is the home on a 100amp service box, 200amp service box, or different amp amount?

Required

What type of HVAC does the home have?

Required

Hold down the Ctrl Key to make multiple selections.

Please advise if you have a free-standing wood/pellet burning stove or if you have an open fireplace. If you have an open fireplace, please advised if it has been framed-in and if it is able to be used or not.

Required

Is there a pool, trampoline, fireplace, wood/pellet stove in the home?

Required

Does the tenant have any pets or dogs? If so, please advise what kind/breed of pet/dog, and how many. If not, please advise if you would allow this down the road for future tenants.

Required

Have there been any property claims in the last 5 years? Please provide details for all properties owned..

Required

Do you have a mortgage? If so, will it be escrow billed?

Optional

Additional Comments

Optional

Submission Validation

Required