Name

Marital Status

Married

Not Married

Birth-date

Second Adult Name

Marital Status

Married

Not Married

Birth-date

Phone # and E-Mail Address

Location-Address of home to be insured:

City—County

State and Zip Code

Georgia

Year Built and Square Feet

Year Purchased

Purchased New

Length and Width

   X

Style (Double or Single)

Doublewide

Singlewide

Park Size and Tie Downs

Tie Downs  Yes  No

Residence type

Residential Owner Occupied

Other

Basement  and Foundation

None Basement Partially Finished Finished

Continous Concrete Pier-stacked Block Pier-Stacked Wood

Garage type & Attached Status

None 1 Car Garage 2 Car Garage 3 Car Garage 1 Car Carport 2 Car Carport

None Attached to Home Detached from Home

Bathrooms 

1 Full Bath 2 Full Baths 3 Full Baths 4 Full Baths                        1 Half Bath None 2 Half Baths 3 Half Baths

Fireplace

None Gas only Wood Optional

Exterior Walls

Plywood Siding Cement Fiber Siding Hardboard Siding Imitation Brick Horizontal Metal Siding Split Log Imitation Stone Stucco Siding Vinyl siding Wood Shake

Roof

Asphalt/Firberglass Shingle Wood Shake Clay Tile Concrete tile Wood shingles Architectural Shingles Rolled Metal Seam Metal  

Flooring

Hardwood Carpet Vinyl Tile Parquet Marble Plank

hardwood Carpet Vinyl Tile Parquet Marble Plank

Heating and A/C

Gas Other-Add Comments

Central AC Window

Skirting

Home has Skirting Home has foundation

Wall Coverings

Paneling Drywall Other

Ceilings

Drywall Textured Drywall Other material

Extras

Jetted Master Tub

Exterior Hot Tub

Screened In Porch

Pool

        (please add comments)

Bay Window

Skylight

Interior Fire Sprinkler System

Fire Extinguisher

Central Burglar/Fire System

Smoke Detector

Dead Bolt Locks

Non-Monitored Security Alarm

Preferred Coverage Amount for the Dwelling:

Deductible Amount:

Quote $500 Quote $1000 Quote Both $500 & $1000

Comments

NOTE: If you current address is different than noted above, please add your address in the comments.

I you are looking for a Landlord policy, Note that in comments too.

Thanks! 

As part of the application process, we may collect personal information from persons other than you or other individuals proposed for coverage, including credit reports and loss information reports. This information, as well as other personal or privileged information subsequently collected by us, may in certain circumstances be disclosed to third parties without your authorization. You have a right of access and correction with respect to all personal information we collect. If you would like more detailed information in writing about our information collection practices, please let us know.

NOTE: In regard to the statement above, we are required to post this as a process of obtaining Loss Information History and final quoting criteria.  Submitting this form approves the collection of data.  We have not asked for and do not require a social security number in this process.

Choosing Submit is also Acceptance of the information noted above: