DWELLING FIRE INFORMATION SHEET

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

 

Effective Date: _______________  Coverage Type:   Home ___  Condo ___   Building ____

 

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 # _________________________

 

                                                                                                  _________________________

 

Dwelling 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: __________________________

 

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

 

# Living Units: ____________       Year Built: ________

 

Construction Type:   Frame __        Masonry __

 

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

 

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

 

If OIL heating, where is tank located?  ABOVE GROUND ___     BELOW GROUND ___

 

Number of Stories:  1    1.5    2    2.5     3     (Please Circle One)   Square Footage: ____________

 

Alarm Type:  Local __   Direct __   Central __

 

Total Room Count:  Bedrooms ____    Full Bathrooms ____    Half Baths ______

 

Basement:    Finished ___   Partially Finished ___    Unfinished ___

 

Garage:  Attached ___    Detached ___    Number of Cars: _______

 

Porch/Deck:  YES __   NO __  If YES, Square Footage: __________

 

Do you have any of the following:  Central Air __   Fireplace ___ Wood Burning Stove ___

 

Laundry Room ___   Pool (Fenced) ___  Sub Zero Appliances ___  Built-In Appliances ___

 

Special Windows/Skylights ___  Trampoline ___

 

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

 

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 __

 

How Many Feet Between Houses: ___________

 

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 ______