“NORTH CAROLINA ONLY”

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 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?	Select... Adobe Bungalow Cape Cod Colonial Contemporary Duplex Log Home Mediterranean Queen Anne Raised Ranch (Bi-Level) Ranch Split Level Timber Frame Traditional Tri-Level Victorian Other
How many stories is your home?	Select... 1 Story 1 1/2 Stories 2 Stories 2 1/2 Stories 3 stories 4 or more stories Bi-level Tri-Level
How many rooms do you have?	Select... 1 2 3 4 5 6 7 8 9 or more
What is the total square footage of the living  area of your home?

WHAT IS THE STRUCTURE OF THE FOLLOWING

Roof:	Select... Architectural Shingles Asphalt Shingle Built Up - Tar & Gravel Clay Tile Concrete Tile Corrugated Steel Fiber Shingles Mineral Fiber Shakes Mission Tile Rock Roof Roll Roofing Rubber Roof Slate Tin Wood Wood Shake
Exterior of your home:	Select... Adobe Aluminum Siding Asphalt Brick Veneer Brick Solid Cement Fiber Clapboard Concrete Block Concrete-Precast Logs Log Siding Mineral Fiber Painted Masonry Slump Block Split Block Stone-Precast Stone-Solid Stone-Veneer Stucco-On-Frame Stucco-On-Masonry Wood Shakes Wood Siding Other
Foundation:	Select... Slab on Grade Crawl Space Piers/Pilings/Stilts Unfinished Basement 25% finished basement 50% finished basement 75% finished basement 100% finished basement Walkout basement Wood foundation basement
Most of the inside walls consist of:	Select... Brick Ceramic Tile Cork Grass Cloth Knotty Pine Mirror Paint Paneling Stone Wallpaper Other
Most flooring consists of:	Select... Carpet over Hardwood Ceramic Tile Flagstone Hardwood Parquet Slate Wall to Wall Carpet Other
Garage:	Select... None Attached - 1 car Attached - 2 car Attached - 3 car Basement - 1 Car Basement - 2 Car Basement - 3 Car Built-in - 1 car Built-in - 2 car Built-in - 3 car Carport - 1 car Carport - 2 car Carport - 3 car Carport w/storage - 1 car Carport w/storage - 2 car Detached - 1 car Detached - 2 car Detached - 3 car
What is the replacement cost of your home:

HOW MANY OF THE FOLLOWING DO YOU HAVE IN YOUR HOME

Full bathrooms:	Select... None 1 2 3 or more
Half bathrooms:	Select... None 1 2 3 or more
Fireplaces:	Select... None 1 2 3 or more
Decks:	Select... None 1 2 3 or more
Enclosed porches:	Select... None 1 2 3 or more
Open porches:	Select... None 1 2 3 or more

DO YOU HAVE THE FOLLOWING IN YOUR HOME

Swimming pool?	Yes No
Trampoline?	Yes No
Burglar alarm?	Select... None Local Central Police station
Sprinkler system?	Select... None Some rooms All rooms
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:	Select... 0 1 2 3 4 or more
What part of the year is the home occupied?	Select... Year round Seasonal (or Snowbird) Occasional Vacation None (Vacant)
Heating and cooling system:
What term best describes your kitchen?	Select... Economy Standard Custom Designer
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?	Select... Local Central Fire station
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):	$ Select... 30,000 35,100 40,250 45,250 50,400 55,500
Personal property/contents (Coverage C - Typically 50% of coverage A):	$ Select... 150,000 165,000 180,000 195,000 210,000 225,000 240,000
Loss of use of your home (Coverage D - Typically 20% of coverage A):	$ Select... 60,000 80,000 100,000 120,000 140,000 160,000 180,000
Personal liability:	$ Select... 1,000 2,000 3,000 4,000 5,000 7,500 10,000 25,000
Medical payments:	$ Select... 1,000 2,000 3,000 4,000 5,000 7,500 10,000 25,000
Desired deductible:	$ Select... 250 500 1,000 2,500 5,000

ADDITIONAL DATA

Quote requested within:	24 hrs  48 hrs  72 hrs 120 hrs
Do you want an umbrella quote:	Select... Yes No I don't know

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 that 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

Quotation Forms

Auto	Home	Life	Business

Best viewed with Microsoft Internet Explorer
Copyright 2004© The Mines Press