Please be sure to complete as many questions from each tab as you can.
First Named Insured:
Spouse Name:
Marital Status: Please Select... Single Married Divorced Widdow/er Other
Mailing Address:
City:
State: Minnesota Wisconsin
Zip:
Phone #:
Email:
Date of Birth:
Highest Level of Education Please Select... High School Diploma GED Some College 2 Year Degree Bachelors Masters Phd Law Degree Other
Occupation:
Property Address:
Property Address 2:
Current Carrier:
Expiration Date:
Current Premium Amount:
Current Dwelling Coverage Amount Coverage A
Current Other Structures amount Coverage B:
Current Personal Property Coverge Amount Covearge C:
Current Loss of Use Coverage Coverage D:
Current Liability Coverage- Coverage E: Please Select... $100k $200k $300k $400k $500k $1,000,000 Other
Current Medical Payments Coverage amount Coverage F: Please Select... $1000 $2000 $3000 $4000 $5000 $10,000 Other
Do you currently have Scheduled personal Property: Please Select... Yes No
Do you currently have personal property Replacement Cost Coverage: Please Select... Yes No Not Sure
Do you have water sewer back up coverage: Please Select... Yes No Not Sure
Do you currently have open peril Personal property coverage: Please Select... Yes No Not Sure
Do you have equipment break down coverage: Please Select... Yes No Not Sure
Do you have Spoiled Property coverage: Please Select... Yes No Not Sure
Do you Have Identiy Theft Coverage: Please Select... Yes No Not Sure
Do you run a business from your home: Please Select... Yes No
If Yes, What type of business:
Liability or Property Loss Claims History (list all losses in last 5 years):
Dates, Types of losses, and Amount paid:
Year Home was Built:
Structure Type: Please Select... Frame Masonry Masonry Vineer Other
Basement/Foundation (select all that apply): Please Select... Basement Slab Basement Walkout Crawl Space
Basement Percentage Finished:
Total Livable Area (above ground or basement):
If home along hill side what is the slope of hill: Please Select... 0-15% 15-30% 30-45% 45%+
Home Style: Please Select... Bungalow SW ADobe Rambler Bi-Level Tri-Level Queen Anne Cape Cod Back-Split Colonial Raised Ranch Contemporary Split Level Mediterranean Row House Victorian Townhouse Ornate Victorian Split Foyer Condo/Co-op Cottage
Number of Stories if home style unknown: Please Select... 1 1 1/2 2 2 1/2 Other
Roofing Type: Please Select... Asphalt/Fierbglass Shingles Clay Tile Wood Shingles Copper Concrete Tile Slate Tar/Gravel Wood Shakes Mission Tile Rubber Tin Architecural Shingles Spanich Tiles Steel Roofing Voctorian Scalloped Shake Other
Primary Wall: Please Select... Block (Painted) Painted Decorative Block Slump Block Poured Concrete 4-6 inch Concrete Walls Solid Brownstone Window Wall Cement Fiber Shingles Hardboard Siding Exterior Insulation/Finish System Wood Siding Wood Shakes T-111 Siding New England Shingle Victorian Scalloped Shakes Plywood Siding (only) Barn Plank Whole Logs Logs - Custom Cedar/Split Log Aluminum Siding Vinyl Siding Steel Siding Stucco on Frame Stucco on Block Brick Veneer Clapboard-Redwood
Secondary Exterior Wall Type: Please Select... Block (Painted) Painted Decorative Block Slump Block Poured Concrete 4-6 inch Concrete Walls Solid Brownstone Window Wall Cement Fiber Shingles Hardboard Siding Exterior Insulation/Finish System Wood Siding Wood Shakes T-111 Siding New England Shingle Victorian Scalloped Shakes Plywood Siding (only) Barn Plank Whole Logs Logs - Custom Cedar/Split Log Aluminum Siding Vinyl Siding Steel Siding Stucco on Frame Stucco on Block Brick Veneer Clapboard-Redwood
Security System Type: Please Select... None Local Central Station
Smoke Detector: Please Select... Yes No
Sprinkler System: Please Select... Yes No
Fire Extingusher: Please Select... Yes No
Heating Type: Please Select... Electric Gas Forced Air Oil Hot Water Other
Does anyone smoke inside the home: Please Select... Yes No
Is this home in a gated community: Please Select... Yes No
Is this home viewable by neighbors: Please Select... Yes No
Central Air: Please Select... Yes Same Ducts Yes Different Ducts No Just Wall Unit
Garage Type: Please Select... Attached Carport – 1 car Attached Carport – 2 car Attached Carport – 3 car Attached Garage - 1 car Attached Garage - 2 car Attached Garage - 3 car Built In Garage - 1 car Built In Garage - 2 car Built In Garage - 3 car None
Attached Structures (select all that apply): Please Select... Attached Porch(open, screened or enclosed) Breezeway (open, screened or enclosed) Attached Deck Greenhouse) Solar Room Balcony Deck
Attached Sturctures total Square Feet:
Special Windows: Please Select... Picture Skylights Solar Panels Bay Windows Stained Glass Other
Number of Special Windows:
Interior fixtures- Flooring Primary: Please Select... Hardwood Hardwood Laminate Cork Carpet Carpet over Hardwood Wall to Wall Carpet Vinyl Ceramic Tile Marble Tile Stone Terazzo
Interior fixtures percentage:
Roofing update (any updates since year house was built): Please Select... Partial Full None
Roofing Update Year:
Electric update (any updates since year house was built): Please Select... Partial Full None
Electric Update Year:
Heating update (any updates since year house was built): Please Select... Partial Full None
Heating Update Year:
Plumbing update (any updates since year house was built): Please Select... Partial Full None
Plumbing Update Year:
Kitchen Type: Please Select... Builders Grade Economy Semi-Custom Custom Designer
Quantity and Type of Full Baths (Number of full baths, builders grade, semi custom, custom, Designer):
Quantity and Type of 3/4 Baths (Number of full baths, builders grade, semi custom, custom, Designer):
Quantity and Type of 1/2 Baths (Number of full baths, builders grade, semi custom, custom, Designer):
Number of Gas Fireplaces: Please Select... 0 1 2 3 4
Number of Wood Burning Fireplaces: Please Select... 0 1 2 3 4
Is there a pool on premise: Please Select... Yes - Above Ground Yes - Below Ground No
If yes, is it fenced: Please Select... Yes No
Electrical System: Please Select... Breaker 60 AMP Breaker 100 AMP Breaker 100+ AMP Fuse
Do you raise or bread horses or dogs? Please Select... Yes No
Do you own any of these breads of dogs? Please Select... Pit Bulls Stafford Terriers Doberman Pinschers Rottweilers German Sheppards Chows Great DAnes Presa Canarios Akitas Alaskan Malamutes Siberian Huskies Wolf-Hybrids
Do you own any rental property? Please Select... Yes No
If yes do you need a insurance quote? Please Select... Yes No
Have you had any claims involving animals? Please Select... Yes No
What is your Required Effective Date?
Liability Coverage Seeking? Please Select... $100k $200k $300k $400k $500k $1 Million Other Same as Current Coverage
Medical Coverage Seeking? Please Select... $1,000 $2,000 $3,000 $4,000 $5,000 $10,000 Other Same as Current Coverage
Do you want replacement Cost coverage for personal Property? Please Select... Yes No Not Sure
Do you want open peril coverage for personal property? Please Select... Yes No Not Sure
Do you want Sewer & water back up coverage? Please Select... Yes No Not Sure
Do you want equipment break down coverage? Please Select... Yes No Not Sure
Do you want Personal Injury protection coverage? Please Select... Yes No Not Sure
Do you want Identity Theft Coverage? Yes No Not Sure
All perils deductible requested? Please Select... $500 $1000 $2000 $2500 $5000 Other
Wind Hail deductible (if different from all perils deductable Minimum of $1,000 deductable): Please Select... $1,000 $2,000 $2,500 $5,000 1% 2% 3% Other
