CONDOMINIUM INSURANCE QUOTE We would like to provide you with a free, no-obligation condominium insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only. This form is hosted on a secure server using SSL technology.

 

Personal Information Primary Insured's Name (First, Last): Gender: Date of Birth: M F Primary Insured's Occupation: How long at current job: Last 4 Social: Highest level edu. completed Spouse's Name (First, Last): Gender: Date of Birth: M F Spouse's Occupation: How long at current job: Last 4 Social: Highest level edu. completed Smoker: Yes   No Have you: filed for Bankruptcy in the last 5 years: Yes  No How many: children live on this property:

How Did You Hear About Us? Please check all that apply: Search Engine Social Network Advertisement Family or Friend Forum/Blog Co-Worker Other:

Property / Contact Information Condo Location Address: City:   State:   Zip: Is the mailing address the same as the condo location address? Y N Mailing Address: City:   State:   Zip: Day Phone:   Night Phone: Best Time To Call:   AM   PM Email Address:

Current Condominium Insurance Information Company Name (not agency): Policy Expiration Date:   Premium Amount: $ Policy Type: Primary Seasonal Rental  Has property insurance been cancelled, declined or non-renewed in last 5 years?  Y   N Number of losses incurred in the last 5 years to the insured's  condo/home or personal possessions at this or another location:  Desired Deductible: $

Condominium Usage Is there a business on the premises?: Y N In-home daycare on the premises?: Y N Dogs on premises of following breeds?: Y N      Akita Chow Doberman Pitbull       Presa Canarious Rottweiler Staffordshire Bull Terrier Wolf Hybrid or mix of any of these

Condo Information Condo is: Owner Occupied Rented to others Seasonal Property Living Area Sq Ft: Number of units in your building: -- Select One -- One Unit 2-4 Units 5+ Units     Year Built: Circuit Breakers?: Yes   No     Does your home have at least one fire extinguisher that is 2 1/2 lbs. or larger?: Yes   No     Do all exterior doors have deadbolt type locks?: Yes   No

Desired Coverages Deductible: Comprehensive Personal Liability: Value of your Contents: -- Select One -- $ 250 $ 500 $1,000 $2,500 -- Select One -- $ 100,000 $ 300,000 $ 500,000 $1,000,000 $ Dwelling Coverage: Loss Assessment: Sewer & Drain Backup: -- Select One -- $ 30,000 $ 40,000 $ 50,000 $ 60,000 $ 70,000 $ 80,000 $ 90,000 $100,000 $100,000+ Yes   No Yes   No Jewelry Coverage: Ordinance & Law Coverage: Yes   No If "Yes", Total Value: $ Yes   No List any additional coverage requirements below:

Structure Information Type Construction Roof Garage 1 Story 1 1/2 Story 2 Story 3 Story Other Frame Stucco Vinyl Siding Brick Veneer Masonry Other Asphalt Shingle Wood Shingle Tile or Slate Other 1 Car 2 Car 3 Car 4 Car None Age of roof: yrs. Attached Detached Basement Built-in Car Port None

Features Bathrooms Deck/Porch/Patio Sq. Feet Fireplaces # of Full:   # of Half:   Deck:   Porch:   Screened Patio:   # of Chimneys:   # of Fireplaces:

Additional Features Heating System Age of Heating Age of Electrical Fire Sprinkler System? Gas/Propane Hot Water Gas/Propane Forced Air Electric/Gas Heat Pump Electric Forced Air/Baseboard Yes Security Alarm Fire Alarm Smoke Detector None Monitored Not Monitored None Monitored Not Monitored Yes

Additional Comments Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter them here.

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