Homeowners Insurance Quote - Alsup and Associates Insurance

Named Insured*

Drivers License Number*

Date of Birth*

Occupation*

Employer*

Email*

Preferred Phone*

Second Named Insured*

Drivers License Number*

Date of Birth*

Occupation*

Employer*

Email*

Preferred Phone*

Property Address*

Street Address Address Line 2 City State ZIP Code

Mailing Address

Street Address Address Line 2 City State ZIP Code

Number of Residents*

Please enter a number greater than or equal to 1.

Any Residents not immediate family?

(i.e. In-laws, grandmother, cousins, roommate(s), etc)

Do you own in whole or partnership any other property?

(i.e. vacation home, farm, grandparents home, rental property, etc.)

Yes
No

If yes, please describe

Homeowner’s Insurance Carrier*

Current Agent*

Current Limits*

Current Premiums*

Current Deductible*

Years with current Carrier*

Homeowner’s Insurance Carrier*

Current Agent*

Current Limits*

Current Premiums*

Current Deductible*

Years with current Carrier*

Have you been non-renewed and/or had your homeowner or auto policy cancelled for any reason in the last 5 years?*

Yes
No

If yes, please provide details on when and why

Any losses (Property or Liability ) in the past 5 years?*

Yes
No

Date of Loss

Details of Losses

Any at-fault accidents in the past 5 years?*

Yes
No

Where and when was your accident?

Any driving violations in the past 5 years?*

Yes
No

What and when were your violations?

Is your property titled in any way other than your name, such as a trust, LLC, family partnership, etc?*

Year Built*

Construction Type*

Number of Stories*

Square Footage*

Type of Roof*

Basement*

Yes
No

Is it finished?

Yes
No

Is it a daylight basement?

Yes
No

Garage?*

Yes
No

Attached or Detached?

Attached
Detached

Replacement cost of your home?

Replacement cost of your contents?*

Would you like to discuss the amount of insurance on your home?*

Yes
No

This amount should be 100% of what it would cost to rebuild your home based on today’s building costs and not the market value. We can assist you in determining the replacement cost for your home.

Are there any other structures on the property?*

Yes
No

(ie. workshop / storage building / deck / pergola / wood fence)

If yes, please describe and include estimated cost to rebuild

Number of fireplaces*

Number of Chimneys*

Number of Full Baths*

Number of ¾ Baths(shower without tub)*

Number of ½ Baths

Type of Heating System*

Do you have a wood stove?*

Yes
No

Do you have a security system?*

Yes
No

Please indicate name and type of alarm

Does it contact the alarm company or 911?

Yes
No

Estimated % of Hardwood, Carpet, Tile, Vinyl, Other

Any elaborate wall-coverings

Yes
No

Home Renovations*

Kitchen*

(basic, builders grade, semi-custom, custom, designer)

Bath*

(basic, builders grade, semi-custom, custom, designer)

Recent Updates

Electrical*

Yes
No

Date

What was done?

Plumbing*

Yes
No

Date

What was done?

Roof*

Yes
No

Date

What was done?

HVAC*

Yes
No

Date

What was done?

Is there a Mortgage on the property?

Yes
No

If so, who is the mortgage company?

Do you own a dog?*

Yes
No

If Yes, what type

(Please include each type for mixed breeds.)

Has it ever bit anyone?

Yes
No

Do you have a pool, hot tub, or trampoline?*

Yes
No

What do you have?

Do you have a Boat, RV, ATV, Motorcycle, Golf Cart, Airplane, Collector car, etc.?*

Yes
No

What do you have?

Do you drive a company car?*

Yes
No

Do you have a dock?*

Yes
No

Estimated cost to rebuild

Do you rent a room(s) to someone?*

Yes
No

Is the room(s) inside the house or separate structure?

Do you run a business or conduct any business operations aside from incidentals (ie. checking work email from home) from your residence premises?*

Yes
No

Do you store any business personal property at your residence premises?*

Yes
No

Value of property

Do you serve on the board of any not-for-profit organization?*

Yes
No

Net-worth?*

Do you have any hobbies that generate revenue?*

Yes
No

Please describe

Do you have a will?*

Yes
No

Do you have life insurance (outside of work)?*

Yes
No

Do you wish to get a quote for Earthquake?*

Yes
No

Has the home been retrofitted?

Yes
No

Do you wish to get a quote for Flood insurance?*

Yes
No

Do you wish to get a quote for an Umbrella?*

Yes
No

Do you have any highly valued or specialty items or collections?*

Yes
No

(ie. art, jewelry, guns, furs, stamps, wine, coins/bullion, baseball cards, silverware, musical instruments, computers, cameras, collectibles )

Describe and give estimate of value

Autos/Vehicles*

Year	Make	Model	VIN	Avg Miles/Year	Use	Commute

Odometer Reading for each vehicle*

Vehicle	Odometer

List any vehicle modifications

Vehicle	Modifications

Days per week driven to work*

Vehicle	Days driven

Do you carpool?*

Yes
No

Garaged other than at your primary residence?*

Vehicle	Yes or No

Student over 100 miles away at school?*

Yes
No

Good student discount?*

A Student
B Student

Percent driven

Vehicle	Driver	Percent Driven

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Phone

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