CONDO/TOWNHOUSE INFORMATION SHEET

Please FAX completed form to Dave at (201) 652-0721

 

Effective Date: _______________                                      Today’s Date: _________________

 

Name(s) as it appears on deed or lease: ____________________________________________

 

                                                           ____________________________________________

 

Owner Date of Birth: ________________       Co-Owner Date of Birth: ___________________

 

Owner Social Security #: _____________        Co-Owner Social Security #: ________________

 

Owner Occupation: __________________      Co-Owner Occupation: ____________________

 

Mailing Address: _____________________________________________________________

 

Location Address (if different): __________________________________________________

 

Telephone Number(s): HOME ____________ CELL ____________ WORK ______________

 

Mortgage Company: __________________________________________________________

 

Mortgage Amount: $ ___________________  Bill to: Insured or Mortgagee (Please Circle One)

 

New Purchase: YES __               If Yes, Market Value: $ _________________

 

                         NO  __   If No, Prior Carrier Name & Policy # __________________________

 

                                                                                                  __________________________

 

                                       Unit Owner Coverage A Limit on Prior Policy: $ __________________

 

                                       Liability Limit on Prior Policy: $ _______________________________

 

                                       Did your Prior Policy:   Cancel __     Non-Renew __

 

                                       If So, Please State Reason Why: ______________________________

 

                                       Date Coverage Ended or Will Cease: ___________________________

 

Requested Unit Owners Coverage A Amount: $ ______________________________________

 

Requested Loss Assessment Coverage Amount: $ _____________________________________

 

Requested Contents Amount: $ ___________________________________________________

 

Requested Liability Amount: $ ___________________________________________________

 

Requested Deductible Amount: $100 __  $250 __  $500 __  $1,000 __ $1,500 __  $2,000 __

 

Residence:  Primary __     Seasonal __              Occupancy:  Owner  __      Tenant    __

 

Year Built: ________                  Construction Type:   Frame __               Masonry __

 

Year of Updates:    Plumbing _____      Electric _____      Heat _____   Roof _____

 

Sump Pump:  YES __    NO __             Heating Type:   GAS __               OIL __

 

                                                            If OIL, where is tank located: ABOVE GROUND  __

 

                                                                                                         BELOW GROUND  __

 

Alarm Type:  Local __  Direct __    Central __

 

Dog or Exotic Animal:    YES __     NO __   If YES, Please List Type of Breed: ______________

 

Any Items to Schedule:  YES __      NO __        If YES, Please Attach Descriptions.

 

Any business Conducted on Premises:  YES __   NO __

 

Any full Time Residence Employees:    YES __   NO __

 

Flood Zone:   YES __      NO __      Located Within 4 Miles of Ocean or Bay:           YES __                 NO __

 

Umbrella Amount Requested: $1 Million __ $2 Million __ If higher, please state amount: _________

 

How did you hear of our Agency? __________________________________________________

 

WE WILL NEED TO ORDER AN INSURANCE SCORE FOR QUOTING.  PLEASE INITIAL WHERE INDICATED FOR PERMISSION TO ORDER SAID DOCUMENT.

 

X ______