Homeowners Quote Form - Davis Independent Insurance Group

Personal Information

1st Name Insured*

Date of Birth*

SSN

Driver's License

Occupation

Home Phone*

Cell Phone*

Email*

2nd Named Insured

Date of Birth

SSN

Driver's License

Occupation

Home Phone*

Cell Phone*

Email

Mailing/Property Address*

Street Address Address Line 2 City State ZIP Code

Previous Address

(if you've lived at current address for less than 2 years)

Street Address Address Line 2 City State ZIP Code

Current Insurance Information

Current Deductible*

Current Insurance Carrier*

Current Dwelling Amount*

Choose a Liability Limit

Policy Start Date*

Renewal Date*

Current Payment*

Known Losses

Home & Property Information

Purchase Date*

Construction Date*

Number living in home*

Number of families*

Miles from fire dept

Responding fire dept*

Fire hydrant near*

Inside city limits*

Yes
No

Exterior Material*

Additional Information

Foundation

Age of Roof

Roof Type

Wood Stove*

Yes
No

Type of Fireplace

Number of Fireplaces

Living Area Sq. Footage*

Type of House

% of Basement Finished

Walkout Basement*

Yes
No

# of Bedrooms*

# Full Bath*

# ¾ Bath*

# ½ Bath*

Heating & Plumbing

A/C Central Air*

Yes
No

Age of Central Unit (years)

Age of Electrical (years)

Age of Plumbing (years)

Kitchen & Bathrooms

Type of Kitchen 1

Type of Kitchen 2

Type of Bathroom 1

Type of Bathroom 2

Garage & Doors

Specialized Doors

Type of Garage

Size of Garage

Other Special Features

Usage & Security

Business Usage

Yes
No

Security System

Yes
No

Monitored

Yes
No

Attached Structures

Attached Structure 1

Size of Structure

Attached Structure 2

Size of Structure

Attached Structure 3

Size of Structure

Detached Structures

Other Detached Structure 1

Other Detached Structure 1 Size

Other Detached Structure 2

Other Detached Structure 2 Size

Swimming Pool

Yes
No

Pool Type

Pool Extras

Trampoline

Yes
No

Pets

Outbuildings

Additional Comments

Vehicles

Vehicle 1 VIN

Driver 1

Vehicle 1 Years owned

Vehicle 2 VIN

Driver 2

Vehicle 2 Years owned

Vehicle 3 VIN

Driver 3

Vehicle 3 Years owned

Vehicle 4 VIN

Driver 4

Vehicle 4 Years owned

Vehicle 5 VIN

Driver 5

Vehicle 5 Years owned

Toys

Toys Owned

Boat
Motorcycle
Travel Trailer
Additional Water Craft
Not Applicable

Comments