SCW Agency

Home Services & Solutions Home Insurance
Homeowners Insurance
homeowners insurance

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
First Name  
Last Name  
E-mail Address  
Daytime Phone Number  
Evening Phone Number  
Fax Number  
How would you prefer to be contacted  
regarding your quote?  		 Phone   Fax   Mail   E-mail  
If you prefer to be contacted by phone,  
what time is 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  
Exterior of your home  
Foundation  
Most of the inside walls consist of  
Most flooring consists of  
Garage  
Replacement cost of your home  

Tell Us About Your Home
Full bathrooms  
Half bathrooms  
Fireplaces  
Decks  
Enclosed porches  
Open porches  

Additional Features
Swimming pool?   Yes No
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

Where 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
Smoke detectors?   Yes No
Fire extinguishers?   Yes No
Fire alarm?  
Deadbolt locks?   Yes No

Additional Information
Gated community with a security guard   Yes No
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
If you have a collection that is anything of value such as coins,  
stamps, art, etc., specify the value of your collection:  		 $
If you have any furs or jewelry,  
please specify the approximate value/limits:  		 $
Do you have any special interests or hobbies  
that could be considered a home based business?  		 Yes No
Do you travel?   Yes No
Do you travel outside of the United States?   Yes No
When you travel, do you bring valuables  
such as watches, jewelry, or furs with you?  		 Yes No
Do you buy things while traveling and want to know  
they are immediately insured under your policy?  		 Yes No
If your home were destroyed,  
would you want to rebuild it in the same location?  		 Yes No
Do you have/want backup of sewers and drain coverage?   Yes No