policy requested
What coverage package do you wish?
Full Package
Fire and Liability
Liability only
Are you interested in mortgage protection?
Yes
No
Coverage Liability
25,000
50,000
100,000
250,000
500,000
1,000,000
5,000,000
10,000,000
Not sure
Coverage Amount?
25,000
50,000
100,000
250,000
500,000
1,000,000
5,000,000
10,000,000
50,000,000
Not sure
Deductible Value?
100
250
500
1000
2000
2500
personal
What is your gender?
Male
Female
Other
What is your occupation?
Employed
Government
Homemaker
Retired
Student living with Parents
Student not living with Parents
Unemployed
Military
Retail
Sales
Marketing
IT
Medical
Unknown
Business Owner
Student
Sales Inside
Sales Outside
Scientist
Other Technical
Military enlisted
Architect
Other
What is your marital status?
Married
Divorced
Separated
Single
Widowed
What is your education level?
Bachelors Degree
Master Degree
Doctorate Degree
High School Diploma
Some College
Associate Degree
Other
None
What is your credit rating?
Excellent
Good
Fair
Bad
What is your type of residence?
Own House
Renting
Student Housing
Other
Years spent at residence?
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80
Months spent at residence?
0
1
2
3
4
5
6
7
8
9
10
11
What type of property is it?
Single Family
Apartment
Duplex
Condo
Townhouse
Mobile Home
Are you the owner of the property?
Yes
No
Are you living in the property?
Yes
No
What is the municipal Lication?
Inside City Limits
Outside City Limits
What is the type of occupancy?
Primary Residence
Seasonal Residence
Vacation
Rental
For sale
Is the property newly purchased?
Yes
No
What is the foundation status?
Basement fully furnished
Basement half furnished
Basement unfurnished
Crawl Space
Slab
Other
What kind of garage?
Attached 1 Car
Attached 2 Cars
Attached 3 cars
Attached Carport
Detached 1 Car
Detached 2 Cars
Detached 3 Cars
Detached Carport
No Garage
Other
How many bathrooms?
1
1.5
2
2.5
3
3.5
4
4+
How many bedrooms?
1
2
3
4
5
5+
Is Home Security available?
None
Monitored
Unmonitored
Unsure
Is a Fire Alarm available?
None
Monitored
Unmonitored
Unsure
What is the Story Level?
One Story
Bi Level
Two Stories
Trilevel
Other
What type of roof?
Asphalt
Wood
Tile
Flat
Metal
Concrete
Slate
Composition
Other
How old is the roof?
1-5
6-10
11+
When was the property build?
2040 2039 2038 2037 2036 2035 2034 2033 2032 2031 2030 2029 2028 2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 1899 1898 1897 1896 1895 1894 1893 1892 1891 1890 1889 1888 1887 1886 1885 1884 1883 1882 1881 1880 1879 1878 1877 1876 1875 1874 1873 1872 1871 1870 1869 1868 1867 1866 1865 1864 1863 1862 1861 1860 1859 1858 1857 1856 1855 1854 1853 1852 1851 1850 1849 1848 1847 1846 1845 1844 1843 1842 1841 1840 1839 1838 1837 1836 1835 1834 1833 1832 1831 1830 1829 1828 1827 1826 1825 1824 1823 1822 1821 1820 1819 1818 1817 1816 1815 1814 1813 1812 1811 1810 1809 1808 1807 1806 1805 1804 1803 1802 1801 1800
When was it last upgraded?
2040 2039 2038 2037 2036 2035 2034 2033 2032 2031 2030 2029 2028 2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
Property Size in Square Foot
How would the construction class be categorized?
Standard
Luxury
Economical
Manufactured
What is the Type of Construction?
Wood Frame
Metal Frame
Brick
Stucco
other
What type of panel?
Circuit Breaker
Fuse Box
Other
Unknown
Proximity water distance?
Not applicable
Within 1000 Feet
Within 1 Mile
Within 5 Miles
What is the primary heating type?
Gas
Electric
Oil
Coal
Wood
Propane
Stove
Other
What type of exterior walls?
Brick
Wood
Stone
Aluminum Siding
Vinyl Siding
Veneer
Cider Block
Stucco
Other
What kind of wiring?
Copper
Aluminum
Knob and Tube
Dog in house?
None
Doberman
German Shepherd
Pit Bull
Rottweiler
Other
features
Deadbolts available?
No
Yes
Fire extinguisher available?
No
Yes
Is there a swimming pool?
No
Yes
Is the swimming pool fenced?
No
Yes
Is there a trampoline?
No
Yes
Floodplain available?
No
Yes
Covered deck or patio available?
No
Yes
Is there a fireplace?
No
Yes
Is there aire station within 5 miles?
No
Yes
Is there a fire hydrant within 1000 feet?
No
Yes
Indoor sprinklers installed?
No
Yes
Copper water pipes installed?
No
Yes
Brush hazard within 500 feet?
No
Yes
Central air condition installed?
No
Yes
Hot Tub available?
No
Yes
Wood burning stove available?
No
Yes
Is there a sump pump?
No
Yes
Is there a smoker in household?
No
Yes
policy current
*Are you currently insured?
No
Yes
Current Insurance Company
Company not listed
21st Century
AAA
AARP
AIG
Access Insurance
AETNA
AFLAC
AIU
Alfa Insurance
All Risk
Allianz
Allied
Allstate
American Alliance Insurance
American Family
American Home Assurance
American Insurance
American International Insurance
American International Pacific
American Internacional south
AMS User Group
American International South
American Direct Business Insurance
American Deposit Insurance
American Casualty
American Manufacturers
American Empire Insurance
American Financial
American Health Underwriters
American Mayflower Insurance
American Motorists Insurance
American National
American Premier Insurance
American Protection Insurance
American Automobile Insurance
American Reliable
American Republic
American Savers Plan
American Service Insurance
American Skyline Insurance Company
American Spirit Insurance
American Standard Insurance
AmeriPlan
Ameriprise
Amica
Answer Financial
Anthem
Arbella
Armed Forces Insurance
Associated Indemnity
Assurant
Atlanta Casualty
Atlantic Indemnity
Atlantis
Auto Club Insurance Company
AXA Advisors
Auto Owners
Bankers Life and Casualty
Banner Life
Best Agency USA
Blue Cross / Blue Shield
Brooke Insurance
Commonwealth
Cal Farm Insurance
California State Automobile Association
Chubb
Cigna
Citizens
Clarendon
Clarendon National Insurance
CNA
Colonial Insurance
Comparison Market
Continental Insurance
Cotton States
Country Insurance and Financial Services
County Insurance and Financial Services
Countrywide
Countywide
CSE Insurance Group
Dairyland Insurance
eFinancial
eHealth Insurance Sercies
eHealthInsurance Services
Electric Insurance
Elephant
Equitable Life & Casualty Insurance
Erie Insurance
Esurance
Farm Bureau/Farm Family/Rural
Farmers
FinanceBox.com
Fire and Casualty Insurance Co of CT
Farmers Union
Fidelity Insurance Company
Fidelity National
Fireman’s Fund
Foremost
Foresters
Geico
AMSUserGroup
Garden State Life Insurance Company
GMAC
Golden Rule Insurance
Government Employees Insurance
Government Empoyees Insurance
Grange
Great American
Great West
Guaranty National Insurance
Guide One Insurance
Hanover Lloyd’s Insurance Company
The Hartford
Guardian
Guideone
Hartford AARP
Health Benefits Direct
Health Care Solutions
Health Choice One
Health Net
Health Plus of AmericaHealthMarkets
HealthShare American
Horace Mann
Horace Mann Insurance
Humana
IFA Auto Insurance
IGF Insurance
IDS
IHIAA
Infinity Insurance
Insurance Insight
Infinity National Insurance
Infinity Select Insurance
Insphere Insurance Solutions
Insurance Shopper, Inc
Insurance.com
Integon
Iroquois Group
John Hancock
Kaiser Permanente
Kemper Lloyds Insurance
Landmark American Insurance
Leader Insurance
Leader Preferred Insurance
Leader Specialty Insurance
Liberty Insurance Corp
Liberty Mutual
Liberty National
Liberty Northwest
Liberty Nothwest
Lincoln Benefit Life
Lumbermens Mutual
Maryland Casualty
Mass Mutual
Mega/Midwest
Matrix Direct
Mercury
MetLife Auto and Home
Metropolitan Insurance Co.
Mid Century Insurance
Continent Casualty
Middlesex Insurance
Midland National Life
Mutual Insurance
National Insurance
Miller Mutual
Modern Woodmen of America
Mutual of New York
Mutual Of Omaha
National Ben Franklin Insurance
National Casualty
Continental Casualty
Continental Divide Insurance
National Continental Insurance
National Fire Insurance
National Health Insurance
National Indemnity
National Union Fire Insurance
Nationwide
New England Financial
New York Life Insurance
Northwestern Mutual Life
Nortwestern Mutual Life
Norhwestern Pacific Indemnity
Northwestern Pacific Indemnity
Omni Insurance
Orion Insurance
Pacific Insurance
Pafco General Insurance
Patriot General Insurance
Peak Property and Casualty Insurance
PEMCO Insurance
Physicians
Penn Mutual
Pennsylvania life
Premier
Primerica
Principal Financial
Progressive
Protective Life
Prudential Insurance Co.
RBC Liberty
Reliance Insurance
Republic Indemnity
Response Insurance
SAFECO
Safeway Insurance
Security Insurance
Senior Market Sales
Sentinel Insurance
Sentry
Shelter
St. Paul Insurance
Standard File Insurance Company
Standard Fire Insurance Company
State and County Mutual Fire Insurance
State Farm
State National
Superior American Insurance
Superior Guaranty Insurance
Superior Insurance
Sure Health Plans
The Ahbe Group
The General
TICO Insurance
TICO Insurance1
TIG Countrywide Insurance
Titan
TransAmerica
Travelers
State Consumer Insurance
Twin City Fire Insurance
UniCare
United Insurance
United American/Farm and Ranch
United Life Group
United Pacific Insurance
United Security
United Services Automobile Association
Unitrin Direct
Universal Underwriters Insurance
US Financial
US Health Group
USA Benefits / Continental General
USA Benefits/Continental General
USAA
USF and G
Viking Insurance
Western and Southern Life
Western Mutual
William Penn
Windsor Insurance
Woodlands Financial Group
Zurich North America
Other
Current coverage package?
Full Package
Fire and Liability
Liability only
claims
*Do you have Claims or Losses in the past 5 years?
No
Yes
Type of Claim
Fire
Hail
Liability
Medical
Theft
Water
Wind
Vandalism
Other
Contact Information
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