Contact Information
Name:
Mail Address:
City:
State:
MA
CT ME NH
RI VT
Zip:
Home Phone:
Work Phone:
Email Address:
Fax:
What is your preferred form of contact to
receive your quote? Home
Phone Work Phone
Fax Email
Mail If phone, best time
to call:
I Would Like A Competitive
Quote
Based on my
CURRENT POLICY which expires: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Insurance Carrier:
For a NEW
HOME PURCHASE, tentative closing date: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Purchase Price $:
Mortgage Amount $:
Desired Coverages
A. Dwelling:
C. Personal Property:
E. Personal
Liability: $100,000
$300,000 $500,000 $1,000,000
F. Medical Payments:
$1,000 $2,000
$3,000 $5,000 $10,000 $25,000
Personal Umbrella
Liability: None $1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000
How many vehicles?
0 1 2 3 4 5
Deductible: $250 $500 $1000
Prior Losses in the last 3 years:
(please describe-- loss type,
date & amount paid):
Information About Your Home
Location of House: if different than address above
Year Built:
Number of Units: 1
2 3 4 5
Number of Stories: 1
1.5 2 2.5 3 3.5 4
Square feet of Living
Space excluding
basement :
Construction: Frame Brick
Veneer Brick Masonry Fire
resistive
Type of
Roof:
shingle mansard slate/tile rubber tar
& gravel wood
shakes
Roof Last
Replaced: (year)
Kitchens & Baths updated in last 25
years? Yes NoKitchens & Baths Last Updated: (year)
Electrical System: Fuses Circut
Breakers
Electrical System Last
Update: (year)
Heating: Gas
Oil More than one
system Heating
Last Update:
(year)If oil, is
tank in the basement? Yes No
Swimming
Pool: Yes No If yes, is pool fenced? Yes No
Garage: None Attached Detached
Do you own a dog? Yes No If yes, what kind of dog?
Home Use: Primary Secondary
Home office
exposure? Yes No If yes, list occupation:
Owner Occupied: Yes NoNon-Smokers: Yes No
Alarm
Systems: Central
Burglar Central Fire
Monitored by Central
Station? Yes No
Safety Systems: Smoke Detector Deadbolts Fire extinguishers Sprinklers
Account Credit
Eligibility
What company insures your
MA Auto?
Renewal Date:
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Is application complete and ready to
submit? Yes