QUICK QUOTE WORKSHEET

APPLICANT'S NAME *

APPLICANT'S DOB *

Address

AGENCY

PRIOR ADDRESS

OCCUPATION

PRIOR CARRIER

LOCATION OF PREMISES IF DIFFERENT FROM ABOVE (UNIT #, CITY, STATE, ZIP) *

CURRENT CARRIER

TARGET PREMIUM *

Our Markets allow us the flexibility to quote risks with non-traditional limits for Coverages B, C & D. Lowering any of these coverages will result in a lower premium, but will most likely not effect the replacement cost on contents.

Please Select *

HO3

HO4

HO6

DP1

DP3

Usage Type *

Primary

Secondary

Secondary/Rental

Tenant Occupied

Vacant

Builder's Risk (contact UW for supplement)

# of weeks rented

Dwelling Limit

Personal Property

Liability

Medical Payments

Other Structures

Loss of Use

AOP Deductible

Wind Deductible

Wind/Hail or Named Storm Deductible

Optional Endorsements (Check box for "Yes"): *

125% ERC

ID Fraud Limit

Water Backup Limit

Earthquake

Replacement Cost on Contents

Personal Injury

Other

Construction

Frame
Masonry
Masonry Ven
EIFs
Log
Other
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Year Built

Square Feet

# of Stories

# of Families

PC

Historical Registry

Gutted and Redone

Roof Type

Update Information

Roof *

Partial

Complete

Plumbing

Partial

Complete

Electric

Partial

Complete

Heating

Partial

Completee

Year

Year

Year

Year

Knob & Tube

Yes

No

Fuses

Yes

No

# of Amps

Galvanized Plumbing

Yes

No

Additional Underwriting Info

1. Swimming Pool

Yes

No

2. Any Bankruptcy or Foreclosure

Yes

No

3. Animal on Premises

Yes

No

4. Lapse in Coverage

Yes

No

5. Claims Information (past 3 years)

Available Credits

General Station Alarm

Gated Community

Storm Shutters

Roof Straps

Hurricane Glass

Pre-Cut Plywood

Remarks

Effective Date Requested

Expiration Date

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