Wiglesworth - Rindom Insurance Agency

HOMEOWNERS RATING FORM

To help us supply you with the most accurate quote possible, please answer as many questions as you can with the most accurate information available to you.

Information submitted will be held confidential and will be used for quote purposes only. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

PERSONAL INFORMATION
First Name:
Last Name:
E-mail address:
Daytime Phone Number:
Evening Phone Number:
Fax Number:
Address:
City:
State:
Zip code:
Date of birth:
Closing Date if new Purchase:
STRUCTURAL INFORMATION
How many stories is your home?
What is the total square footage of the living area of your home?
Do you have a Screen Enclosure that extends beyond the roof line of the home?	Yes No
If yes what year was it constructed?
WHAT IS THE STRUCTURE OF THE FOLLOWING
Roof:
Exterior of your home:
Garage:
What is the replacement cost of your home:
IS YOUR HOME LOCATED
Within 1000 feet of a fire hydrant?	Yes No
Within 5 miles of the fire station?	Yes No
GENERAL QUESTIONS
Year home built:
What part of the year is the home occupied?
What term best describes your kitchen?
Did you experience any loss or claims in the last 5 years? If yes please list details in remarks.	Yes No
Dog?	Yes No
Dog Breed:
PROTECTIVE DEVICES
Fire alarm?
Burglar alarm:
Engineered Hurricane Shutters?	Yes No
Gated community:	Yes No
24 Hour Guards at the Gate:	Yes No
Do the Guards Patrol the Community:	Yes No
HOMEOWNERS COVERAGES AND DEDUCTIBLES
Dwelling (Coverage A - Replacement cost of your home):	$
Desired deductible:	$
REMARKS

QUOTATION FORMS
HOMEOWNERS | AUTOMOBILE | FLOOD