HOMEOWNER QUOTE REQUEST

Please fill in as much information as possible, as it will help us serve you more effectively.

Applicant Information

Name (required)

Mailing Address

City

State

Zip Code
 

Physical Address

City

State

Zip Code

Phone

Fax

E-Mail (required)

Property Information

Dwelling Limit

$

Other Structures Limit

$

Personal Property Limit

$

Loss of Use Limit

$

Personal Liability Limit
$

Medical Payments Limit

$

Year Constructed

Structure Type
Dwelling
Apartment
Condominium

Townhouse
Row house
Co-op

Framing
Wooden Frame
Masonry
Masonry Veneer

Vinyl Siding
Aluminum Siding

Usage Type
Primary
Secondary
Seasonal

Farm

Protection Type

Smoke Alarm
Central  Direct  Local

Burglar Alarm System
Central  Direct  Local

Temperature Control
Central  Direct  Local

Choose all that apply
Deadbolt  Fire Extinguisher  Visible to Neighbors

Premises

Any framing or other businesses conducted on premises?
Yes  No 

Any residence employees?
Yes  No 

Any flooding, brush, forest fire hazard, landslide, etc?
Yes  No 

Any other residence owned, occupied, or rented?
Yes  No 

Any coverage ever been declined, cancelled, or non-renewed?
Yes  No 

Has applicant had a foreclosure, repossession, bankruptcy, judgment or lien during the past five years?
Yes  No 

Are there any animals or exotic pets kept on premises?
Yes  No 

Is property located within two miles of tidal water?
Yes  No 

Is property situated on more than five acres?
Yes  No 

Does applicant own any recreational vehicles?
Yes  No 

Is building retrofitted for earthquakes?
Yes  No 

Has applicant been convicted of any degree of crime or arson within five years (10 in Rhode island)?
Yes  No 

Any uncorrected fire or building code violations?
Yes  No 

Is the building undergoing renovation or reconstruction?
Yes  No 

Is house for sale?
Yes  No 

Is the property within 300 feet of a commercial or non-residential property?
Yes  No 

Is there a trampoline on the premises?
Yes  No 

Was the structure ever built for something other than residence then converted?
Yes  No 

Any lead paint hazard?
Yes  No 

If premises contains a fuel oil tank, has other insurance been obtained for the tank?
Yes  No  N/A

If the building is under construction, is the applicant the general contractor?
Yes  No   N/A

For Renters and Condominium Only (check all that apply)
Manager on Premises
Security Attendant
Building Entrance Locked

Comments

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