Home Insurance Quotation Worksheet
Accord Home Owner Application

Present Company:       Premium:      Effective Date:

Date:                                                                Producer:
Name: 
Address: 
Home Phone: When:  Business Phone: When:
Occupation/Employer:   DOB:   SS#: 
How did you hear about our agency:
May we offer you a quote on your auto insurance:  Present Co: Exp.Date:

Coverages:

What Form: HO 1 Basic   HO 2 Broad   HO3 Special   HO 4 Tenant   HO 6 Condo
A: Personal Property: $25,000  $,50,000   Other
B: Liability: $100,000  $300,000  $250,000/500,000  Other
C: Loss of Use: $20,000  Other:
D: Medical Payment: $5,000   Other:
E: Dwelling Structure: $100,000  Other
F: Other Structure: 
G: Additions/Alterations: 
H: Additional Premises Rented   Others
I: Deductibles: $250   $500   $$250/500THFT   Other

Other Endorsements:
Jewelry:    Furs:    Other:

Underwriting:
1. Primary Residence:   Secondary Residence:   
2. Wood   Masonry   Fire Resistive
3. Year Built   * Year Systems Renovated:  Electrical Plumbing Heating   Roof
4. Swimming Pool:  Y N Above Ground Below   Fenced: Y N
5. 24 Hour Doorman:  Y N  
6. Number of Dogs:   Breed:
7. Wood Burning Stove:  Y N  
8: Alarm Credits: Smoke alarms only: Y N   Central Station: Fire   Burglary Local Alarm: Fire Burglary
9. Dead Bolt Locks: All Doors Y N   
10: Distance from Fire Station:
11: Distance from fire Hydrant:
12: All Household Residence Non-Smokers: Y N  
13: Mortgagee:

List any claims' Dates, Descriptions, and Amounts Paid:

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