Premier Services - The Insurance Experts

Homeowners Insurance Application
(Quotes will be provided for Pennsylvania, New Jersey)

The more information you can provide to us, the quicker we can respond back to you with our lowest price.

Applicants:

Address:

City, State, Zip Code:

Phone:

Fax:

E-Mail:

Age:

Occupation:

List any pets:

Dog breed:

History of biting:

Property Information

Do you live in a home now?

If yes, do you currently have home insurance?

If no, please explain below in the additional comments box why you do not have home insurance and how long is the lapse of insurance:

Reason for wanting a quote:

Please explain other in the additional comments box below.

What is the settlement date, or if you are currently insured, what is the expiration date?

If this is a settlement, then please fill in the address of the home to be insured (include street address, city, state, zip and COUNTY):

Present market value of home/sale price:

Approximate total mortgage owed:

Age of home:

Is this home a:

Number of families:

Occupied by:

Enter dwelling type:

Is the fire department within 5 miles?
Yes No

Is a fire hydrant within 1000 feet? Yes No

Any boarded or vacant properties on the block?: Yes No

Any commercial properties?: Yes No

Construction material:

Roof age (replaced year):

Roof material: List other

If flat roof, list year when last hot coated:

Pitch of roof (please select one):

Heater age:

Heat fuel:

Heat type:

If oil heat, is oil tank: Above ground In ground

If in ground, list age and warranty by:

Any supplemental heating? Yes No

If yes, type of heating: List Other

Plumbing age:

Age of bath:

Age of kitchen:

Age of electric:

Type of electric:

Amps:

Number of rooms:

Living Room:

Dining Room:

Bedrooms:

Kitchen:

Full bath:

Half Bath:

Family room:

Den:

Attic:

Breakfast nook:

Foyer:

Enclosed porch:

Open porch:

Deck:

Storage Room:

Basement:

Fireplace:

Walk in closet:

Central air:

Garage type:

Size of garage:

Swimming pool:

Is swimming pool:

Do you have a trampoline?

For the two questions below, please enter the width and length of the first floor of the house. Exclude attached garages, decks, porches and additions from your measurement

Approximate width of house in feet (do not include land):

Approximate length of house in feet (do not include land):

Current insurance carrier (if applicable):

Premium paid:

State the number of claims within the past five years:

Please explain the details of your claims in the additional comments box below:

Applicant 1: Please rate yourself in terms of "paying bills on time":

Do you have a home based business to earn income?

If yes, please explain your home base business in the additional comments box below:

Applicant 2: Please rate yourself in terms of "paying bills on time":

Do you have quotations from other companies? Yes No

Would you like a quote to easily compare prices based on either the same coverage as your lowest quote or based on your present home insurance policy? Yes No

If yes, which price to compare to: Lowest quote
Present insurance policy

Who is the insurance company?

What was the price quoted?

What is the dwelling coverage/amount for the above price?

What is the deductible for the above price?

How much is the liability coverage for the above price?

How did you hear about us?

Additional Comments: