Easy Home Proposal Request

Full Name *

Address *

City *	State *	Zip Code *	Country *

If outside city limits, name of responding Fire Department.	Miles to Dept	Feet to Hydrant

Social Security #	Square Footage	# of Stories

It is:	I live in or own a:
Owner-occupied Rented to others 1 2 3 4+ Person Family	Dwelling Co/op Home Own a condo

Construction Type
Frame Brick Over Frame Solid Masonry Other (specify)

Home Extras *
Year Built		Smoke Detectors	Yes No
Central Station Burglar	Yes No	Dead Bolts	Yes No
Central Station Fire	Yes No	Fire Extinguisher	Yes No

Have any of the following systems been updated in last 20 years? *
Roof	Yes No	Plumbing	Yes No
Heating	Yes No	Electrical	Yes No

Other Questions
Do you have a service contract? *	Yes No
Type of heat?
If oil, where is tank stored? Underground Above Ground Basement
Electrical system protected by circuit breakers? *	Yes No
Do you need special coverage for Jewelry, Furs, Cameras, Fine Arts, etc?*	Yes No
If yes, describe item and value:
Have you had any losses to your home or property in the past 3 years? *	Yes No
If yes, describe (include date of loss):
Do you own a Swimming Pool? *	Yes No
If yes, type (ie. Aboveground or Underground): Fanced Diving Board/Slide
Do you have a Wood Stove/Pellet Stove? *	Yes No
Do you own any Animals or Exotic Pets? *	Yes No
If yes, type (ie. Dog, Cat, Bird, House, Other): Breed:
Do you own or rent any other property? *	Yes No
Do you conduct any business out of the home? *	Yes No

Current Insurance Company	Current Policy Expires*	Current Premium

If Renting: Number of apartments in your building
Dwelling or Building Coverage Limit $
Value of Personal Property or Contents


Deductible	$250 $500 $1,000
Medical Payment	$1,000 $5,000
Personal Liability Limit	$100,000 $300,000 $500,000 $1,000,000

Fair Credit Reporting Act Notice: We are required to inform you that as part of our underwriting procedure, a consumer report may be requested. Additionally, subsequent consumer reports may be requested on renewal or as an update on your insurance application. Upon your written request, you will be informed whether or not a consumer report was requested, and if so, the name and address of the consumer reporting agency to whom the request was made.