Personal Home Insurance

• Effective Date:

• Name :

•Prior Address if less than 3 yrs or present Address if new purchase : 

• Home Telephone Number :

•Social Sec#  of one person :

•Date of Birth of one person :

•Type of Structure – dwelling, townhouse, etc. :

•  # of Families ( ie: Single Family or Two Family Etc. ) :

• Gas or Oil Heat (if oil, need age of tank and if it is above or below ground, need tank insurance and inspection certificate) :

• Number or Stories               and type of House (Ranch, Colonial, etc) :

• Exterior Walls of house - vinyl, brick, wood  :

• Square feet of living area :

•  sq ft of Basement-if finished or is house on slab, crawl, unfinished :

 • # car Garage, Attached with no rooms above, Built In or Detached :

•  Deck, sq ft, type such as Wood, Trex, Redwood :

•  # Bathrooms, Full and Half :

• Central Air-same Ducts or separate Ducts from Heating System :

 • electric, Circuit breakers? and yr of update :

• Any Secondary Heating Source – Wood Stove :

 • Roof, age and if repaired, year repaired-ype, asphalt, slate, is it pitched? :

• Plumbing, type- copper, pvc year updated :

• Any Sliding Doors, French Doors, Specialty Windows (picture, atrium, etc), Skylights & size, Jacuzzi, Hot Tub, Pool and Type:

In Ground or Above Ground, Trampolines :

• Central Alarm System yes or no, Smoke Detectors yes or no, Fire Extinguisher yes or no, Deadbolts yes or no :

• Updates to Plumbing, Electrical and Heating and age of Roof – complete or partial & year :

•Any Pool ?           if yes Diving Board, Slide, is it Fenced ? :

• Any Prior Claims ?  :

•Any Prior Cancellations ? :

• Any Prior Insurance Carrier ? :

• Mortgage Information – Name and Address :

• Is Mortgagee to be billed on Renewal  ? :

• Any Additional Coverages needed ?:

• Scheduled Items such as Jewelry, Furs, etc :

•Amount to insure House :  $

•Purchase Amount  : $

•Mortgage Amount $

•Deductible :  $

Provide the Information that you know and feel comfortable with provinding at this point. 

 By providing this this Information we can offer you a quote for Insurance that best suits your needs. As always qoutes are provided with no Obligation and hopefully will provide you with an Option for the Best Cost  Benefit for the Coverages you require.  Please consider giving us an Honest Opportunity to serve you.

If you have any Questions you can contact me by phone : 732-558-8968  ( leave a Message and I will return it promptly) or Email by clicking on the following Link : Rudy205@Comcast.net.