HOMEOWNERS INSURANCE QUOTATION FORM

To help us supply you with the most accurate quote possible, please answer as many questions as you can with the most accurate information available to you.

Information submitted will be held confidential and will be used for quote purposes only. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.


PERSONAL INFORMATION
Your name:  First:      Last:
E-mail address: 
Phone numbers:  Daytime:
Evening:
Fax:
How would you prefer to be contacted 
regarding your quote? 

Phone   Fax   Mail   E-mail

If you would prefer to be contacted by phone, 
please let us know the best time to call. 		 AM PM
Address: 
City: 
State: 
Zip code: 
Social security number:
Occupation:
Date of birth: 
Employer:
STRUCTURAL INFORMATION
What is the style of your home? 
How many stories is your home? 
How many rooms do you have? 

What is the total square footage
of the living area of your home? 
WHAT IS THE STRUCTURE OF THE FOLLOWING
Roof: 
How old is the roof?
Exterior of your home: 
Foundation: 
Most of the inside walls consist of: 
Most flooring consists of: 
Garage: 
What is the replacement cost of your home: 
HOW MANY OF THE FOLLOWING DO YOU HAVE IN YOUR HOME
Full bathrooms: 
Half bathrooms: 
Fireplaces: 
Decks: 
Enclosed porches: 
Open porches: 
DO YOU HAVE THE FOLLOWING IN YOUR HOME
Swimming pool? 
 Yes No
Is the pool screened?
Trampoline? 
 Yes No
Burglar alarm? 
Sprinkler system? 
Kerosene, wood or oil stove? 
 Yes No
Dog? 
 Yes No
Computer? 
 Yes No 
Livestock?
Yes No
Unusual/exotic pets? 
 Yes No
IS YOUR HOME LOCATED
Within 1000 feet from a fire hydrant? 
 Yes No
Within 5 miles from the firestation? 
 Yes No
On a hillside? 
 Yes No
Close to a body of water or susceptible to flooding? 
 Yes No

GENERAL QUESTIONS

Year home built: 
Number of families living in the home: 
What part of the year is the home occupied? 
Heating and cooling system: 
What term best describes your kitchen? 
Is business conducted on the premises? 
 Yes No
Does anyone in your home smoke? 
 Yes No
Did you experience any loss or claims in the last 5 years? 
 Yes No
PROTECTIVE DEVICES
Hurricane shutters or impact windows?
Smoke detectors?
Yes No
Fire extinguishers?
Yes No
Fire alarm?
Deadbolt locks?
Yes No
ADDITIONAL INFORMATION
Gated community with a security guard: 
 Yes No
Name of community?
Neighborhood watch program: 
 Yes No

Senior citizen discount
(all occupants age 55 or above): 

 Yes No
HOMEOWNERS COVERAGES AND DEDUCTIBLES

Dwelling
(Coverage A - Replacement cost of your home): 

 $
Other structure
(Coverage B - Typically 10% of coverage A): 
 $
Personal property/contents
(Coverage C - Typically 50% of coverage A): 
 $
Loss of use of your home
(Coverage D - Typically 20% of coverage A): 
$
Personal liability: 
 $
Medical payments: 
 $
Desired deductible: 
 $
ADDITIONAL DATA
Quote requested within: 
 24 hrs  48 hrs  72 hrs   120 hrs
Do you want an umbrella quote: 
OPTIONAL QUESTIONS
Is this a new purchase? 
 Yes No
If yes, closing date.
 $
If no, current insurance company?
Is current insurance company non-renewing?
 Yes No
If yes, non-renewal date?
If no, renewal date of current policy?
Which agent at Landmark Insurance would like to work on your quote?





Quotation Forms


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