Home/Dwelling Fire qualify Form

APPLICANT INFORMATION
First Name:
Last Name
Address:  
City:
State:
Zip:
Phone:
Email: Is it ok for us to run your insurance score? Yes No
Husband Social
Security Number		 Date of Birth :   
Wife Social
Security Number		 Date of Birth :   
Claims on any home in the last 5 years.
Amount paid out on claim(s):             
Who are you currently insured with ?                  Expiration Date:   
How long1 at current address?                   Previous Address:
New Purchase?
Yes No
Deductible (We will run replacement cost to get value of home)
250 500 1,000 2,500
Construction of Home:   Brick Veneer Frame Masonry Rock Vinyl/Aluminum Siding
Age of Home:          County:          Protection Class:
Feet to a fire hydrant:          Miles to a fire hydrant:          Fire dept name:
Fuse Box Breaker Box Burglar Alarm: Local Central Inside City Limits: Yes No
Deadbolt Yes No           Smoke Detector Yes No           Fire Ext Yes No           Trampoline Yes No
Swimming Pool:  Yes No                    If Yes Above Ground In Ground                    Fenced: Yes No
Do you have a pet?  Yes No If dog what breed? Has it ever bitten anyone? Yes No
Farm barns, outbuildings, sheds? Yes No                    If yes what type of building?
Any items to schedule such as guns, jewelry, furs, fine arts, silverware?                   Amount of coverage desired:   
Square Feet:                    # of Stories:               Basement: Yes No                    Crawl Space Slab
Garage Carport
Attached Detached		 # of car(s):     Number of bath(s)
How do you heat your home?                   Fire Place Yes No                   If yes? Gas Wood
Heat/Cool unit age: Plumbing Age:     Wiring Age:    
Roof Material:         Roof Age:       
How did you hear about our Agency?: