Homeowners Referral

 

Please put down as much information as you have on the consumer.  Also to remember to put your name down as the Referring Agent Name.

 

Effective Date:   When would you like new coverage to start?
Contact Name:                     Referring Agent Name: 
Contact Physical Address: Street

City & State, Zip
  
Date of Birth: ie- 09/01/1970
E-mail Address:
Daytime Phone #:
Social Security #
Type of policy desired:   Homeowners, Condo or Renters
 
Amount of insurance desired:
Homeowners only:
What is the value of your home?

Condo/Renters only:
What is the value of your personal property? 		 
Property Information:
What is the construction type of your Property?
Brick, Wood, Siding, etc... 		In what year was your home built?
In what County/Township are you located?
 Distance to the nearest fire hydrant?
What kind of pets do you have?
 Do you have a swimming pool?
Yes No
Do you have a trampoline?
Yes No 		Do you use a wood burner?
Yes No
Smoke Detector(s) Installed
Home Security System Installed
 		  
Home Updates:  Enter year updates were made. If year not known, enter "unknown":
Roof:


Wiring:
 Plumbing:


Heating:
Optional Property Coverages:
Earthquake Coverage Requested
Flood Coverage Requested
Sewer/Water Backup Coverage Requested
Property Floaters - Indicate limits below:
 
Antiques:


Coins:


Computers:


Fine Arts:
 Furs:


Jewelry:


Stamps:


Tools:
Other Floater Coverage:     Limit of Insurance:
           
Previous Loss Information
Please describe any losses or claims filed on your Homeowners Insurance in the last 3 years:
Be sure to include the date of loss, type of loss and the amount of the claim.
Additional Comments
Please use the box below to enter any additional information you wish to include: