Agent Information
Agent Name:
Phone:	Fax:
Email Address:

 

Required*   Applicant acknowledges that a CLUE Report CLUE Report Comprehensive Loss Underwriting Exchange: Underwriters use the information in a CLUE report to rate insurance policies. A home's CLUE loss history report provides insurance company names and policy numbers and any claim numbers. The report lists the dates of any claims, the loss types and amounts paid for losses, and it will tell if a claim was denied. may be obtained during the quoting process

 

Applicant's Personal Information
Applicant Name:	DOB:   Gender: Male Female
Marital Status:	Select... Married Divorced Single Domestic Partner Widowed   Occupation:
Co-Applicant Name:	DOB:   Gender: Male Female
Marital Status:	Select... Married Divorced Single Domestic Partner Widowed   Occupation:
Property Address:
City:	State:   Zip:
In City Limits?:	Yes   No
Prior Address: (If at Property Address less than 2 years)
City:	State:   Zip:
Mailing Address: (If different from Property Address)
City:	State:   Zip:
Phone:
Email Address:

Current Homeowners Insurance Information
Company Name (not agency):
Policy Information:	Expiration Date	Premium Amount	Amount Insured For
		$	$
Occupancy:	Primary Secondary Tenant Vacant      If rental, how many units owned by the applicant:   1 - 5 6 - 10 11 - 15 16 - 20
Current Deductible:	$     # of Mortgages: 0 1 2 3
# of Claims In Last 3 Years:	Date:	Amount:	Details:
		$
		$
		$

New Coverage Information
Amount of Coverage Desired:	$
Desired Deductible:	$ 500 1,000 2,000 5,000
Personal Liability:	$ 100,000 300,000 500,000
Earthquake Coverage:	Yes   No
Extended Coverage:	$ 125 150

Home Information
How Long At Present Address:	Year Home Was Built:
Swimming Pool?:	Yes No         If Yes, Diving Board: Yes No
Any Pets?:	Yes No If Yes, what kind / how many:
Sq. Footage: (excl. garage/basement)	sq. ft.       # of Units: 1 2 3 4
Miles to Responding Fire Dept.:	0-5 Over 5     Feet to Fire Hydrant: 0-500 501-1000 over 1000
If home is more than 20 years old, please provide updated information for the following:
Roof:	Year Updated:   Complete Partial None
Electrical:	Year Updated:   Complete Partial None
Heating:	Year Updated:   Complete Partial None
Plumbing:	Year Updated:   Complete Partial None

Structure Information
Type	Construction	Exterior Walls	Roof	Foundation	Garage
1 Story 1 1/2 Story 2 Story Split Level Bi-Level Other (list below)	Frame Stucco Veneer Masonry Other (list below)	Stucco Wood Siding Brick Other (list below)	Asphalt Shingle Wood Shingle Tile or Slate Other	Slab Crawl Space	1 Car 2 Car 3 Car 4 Car None
			Age of roof: yrs.		Attached Detached Basement Built-in Car Port None

Features
Bathrooms	Basement	Deck/Porch/Patio Sq. Ft.	Fireplaces
# of Full:   # of Half:	None Finished Unfinished   Sq. Ft.:	Deck:   Porch:   Screened Patio:	None Brick Built-in w/ Wood Chimney # of Chimneys:   # of Hearths:

Additional Features
Heating System	Gas Shutoff Valve	Central Air	Central Vac	Security Alarm	Fire Alarm	Smoke Detector
None Electric Gas Oil Propane Solar Other	Yes	Yes	Yes	None Monitored Not Monitored	None Monitored Not Monitored	Yes

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter them here.

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