HOMEOWNERS INSURANCE QUOTE

Transcription

1 HOMEOWNERS INSURANCE QUOTE NAME:,SPOUSE. PHONE#: ENUUL: NUULING ADDRESS & PHYSICAL ADDRESS SAME?: SS #: :I DOB: I Year of Construction Construction Type Square Footage # Stories Primary/ Primary Bedrooms Seasonal Heat Bathrooms I #cars Garage Roof Type Age of Roof Shape Roof Hurricane Shutters Alarm/Fire Screened Open Golf/ System Patio (size) Patio (size) Boat Swimming Pool Diving Slide Trampoline More than 5 acres AGE MORE THAN 25? PLUMBING ELECTRIC HEAT AJC ROOF 4 POINT INSPECTION? Upgrades: Kitchen Bathroom (Marble or Granite) Animals:,Bite History? ANY SCHEDULED ITEMS:. CURRENT INS. CO.? EXPIRATION DATE: CLAIMS I LOSSES REPORTED? FLOOD INSURANCE COMPANY: CURRENT MORTGAGE CO I ADDRESS I LOAN CURRENT OCCUPATION: ANY BUSINESS CONDUCTED AT HOME? HOW DID YOU HEAR ABOUT US? I REFERRAL SOURCE: INFO TAKEN BY: DATE: ASSIGNED TO:

2 BOAT/WATERCRAFTINSURANCEQUOTE NAME: PHONE#: GARAGING: HOMEOWNER?: MARRIED?: AUTOPOUCY: INSURED SS# DOB DL# BOAT /WATERCRAFT: YEAR/MAKE/MODEL DESCRIPTION SERIAL NUMBER (Hull!D) HULL INFO: HULL LENGTH HULL MATERIAL TOTAL VALUE (incl trailer) #OF MOTORS REGISTRATION NUMBER TOTAL HORSEPOWER LOSS PAYEE: lvlax SPEED PROPULSION TYPE (OUTBOARD /INBOARD) (OUTBOARD /INBOARD) TRAILER: YEAR I MAKE I MODEL DESCRIPTION REGISTRATION NUMBER LIMITS REQUESTING: BI: COMP & COLL. DEDUCTIDLE: PD: UB: MED:-;P::cAc;Y-;-: P"'E:-: WATER TOW: BAHAMAS: ROADSIDE: ADDITIONAL EQillP. (fishing, scuba, etc.): RENTAL?: TOWING?: COVERAGE REQUESTED (pip & bodily injury required?) ACCIDENTS NIOLATIONS I ARRESTS? REFERRAL SOURCE: INFO TAKEN BY: DATE:

3 COMMERCIAL LIABILITY & PROPERTY QUOTE REGISTERED CORPORATE NAME: PHONE#: FAX#: E~IAIL: CONTACT PERSON: TAX ID #: YEARS IN BUSINESS NATURE OF BUSINESS: OWNERS SS# DATE OF BIRTH % OF OWNERSHIP TOTAL NUMBER OF EMPLOYEES: YEARLY GROSS RECEIPTS: $ CURRENT LIABILITY CARRIER: BUILDING VALUE:$ TOTAL PAYROLL:$ SQUARE FOOTAGE OCCUPIED: EXP DATE: CONTENTS VALUE: $. EQUIPMENT TO INCLUDE FOR PROPERTY COVERAGE: EQUIPMENT VALUE CURRENT PROPERTY CARRIER: -:-:---:--:- ANY LOSSES IN THE PAST 3 YEARS: Letter on company letterhead stating no losses if none obtained Past 3 years loss runs ordered CURRENT W/C CARRIER:=-:::-:=--= EXP DATE:---- CURRENT GROUP HEALTH CARRIER: EXP DATE: CURRENT ACCIDENT I DISABILITY CARRIER: EXP DATE: CURRENT COMMERCIAL AUTO CARRIER: EXP DATE: ADDITIONAl. INFORMATION:

4 BUILDERS RISK QUOTE OFFICIAL CORPORATE NAME: PHONE#: FAX#: CONTACT PERSON: NATURE OF BUSINESS: #OFYEARSINBUSINESS: TAXID#: PROPERTY LENGTH OF TIME TO POSSES PROPERTY: CONSTRUCTION: VALUE OF PROPERTY: SUBCONTRACTORS: LOSSES IN PAST 3 YEARS: LETTERONCOMPANYLETT~E~RH~EAD~~ST~A~T~IN~G~N~O~L~O~S~S~E~S~IF~N~O~N~E~ PAST 3 YEARS LOSS RUNS (HISTORY OF LOSSES FROM PREVIOUS I EXISTING COMPANY) CURRENT LIABILITY I PROPERTY COVERAGE: COVERAGE REQUESTING: CURRENT WC COVERAGE: CURRENT GROUP HEALTH COVERAGE: CURRENT ACCIDENT (AFLAC) COVERAGE: CURRENT AUTO COVERAGE: CURRENT LIFE COVERAGE: ADDITIONALINFORMATION: REFERRAL SOURCE: INFO TAKEN BY: DATE:

5 COMMERCIAL AUTO INSURANCE QUOTE COMPANY NAME: CONTACT NAME: NATURE OF BUSINESS: ORGANIZATION TYPE: PHONE#: GARAGING DRIVER SS# DOB MARRIED DL# CAR MAKE /MODEUIYPE CARVIN STATED AMOUNT FEATURES (ALARMS, ABS, AIRBAGS): LOSS PAYEE LOSS PAYEE #2: LOSSPAYEE#3: PRIMARY USE: RADIUS: DELIVERIES/JOB SITES PER DAY TYPE OF TRAILER HITCH TRAILERS: MAKE & MODEL: CARRIER OF PRIOR COVERAGE: PREVIOUS POLICY NUMBER: EXPIRATION DATE: LIMITS REQUESTING: BI: COMP & COLL. DEDUCTIBLE: PD: UM: MED.--:P:ccAc::Y~:------=woRK 7 L 00 S::-:S:-: TOWING: RENTAL: PIP DED: ADDITIONAL EQUIP.: CURENT COMMERCIAL LIABILITY I PROPERTY INS. CURRENT WC INS: CURRENT GROUP HEALTH INS. CURRENT ACCIDENT I DISABILITY INS. CURRENT LIFE INS CARRIER: ADDITIONAL INFORMATION: REFERRAL SOURCE: INFOTAKENBY: DATE:

6 AUTO INSURANCE QUOTE NM~E: PHONE# GARAGING HOMEOWNER?: MARRIED? INSURED SS# DOB DRIVERS LICENSE NUMBER ACCIDENTS NIOLATIONS I ARRESTS? CAR YEAR I MAKE I MODEL VIN PRIOR COVERAGE: "EXP DATE: LIMITS REQUESTING: Bodily Injury Prop Damage U/M Comprehensive Ded Collision Ded Med Pay TOWING: RENTAL: PIP DED: ~----- CURRENT HOMEOWNERS INS. CARRIER: HOW DID YOU HEAR ABOUT US? I REFERRAL SOURCE: INFO TAKEN BY: DATE: ASSIGNED TO: