The Hart Smith Company: Homeowners Quotation Form

HOMEOWNERS QUOTATION FORM

To help us supply you with the most accurate quote possible, please answer as many questions as you can with the most accurate information available to you.

Information submitted will be held confidential and will be used for quote purposes only. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

Please note that completion of the following request for information does not constitute the purchase of insurance. No coverage may be added, changed or bound as a result of submitting this request for information or quotation of insurance. All coverage must be confirmed by the agency in writing subject to an acceptable signed application meeting the underwriting guidelines of the insurance company.

The Hart Smith Company is licensed in the state of Georgia. No solicitation of insurance is being made outside of this state.

Personal Information
Your name
E-Mail address
Phone numbers	Daytime
	Evening
	Fax
How would you prefer to be contacted regarding your quote?	Phone Fax Mail E-Mail
If you would prefer to be contacted by phone, please let us know the best time to call.
Address City State, Zip
Do you currently own your home, or rent?	Own Rent
Occupation
Social security number
Employer
Date of Birth

Structural Information
What is the style of your home?
How many stories is your home?
How many rooms do you have?
What is the total square footage of the living area of your home?

What Is The Structure of The Following
Roof:
Exterior of your home:
Foundation:
Most of the inside walls consist of:
Most flooring consists of:
Garage:
What is the replacement cost of your home:

How Many Of The Following Do You Have In Your Home
Full bathrooms:
Half bathrooms:
Fireplaces:
Decks:
Enclosed porches:
Open porches:

Do You Have The Following In Your Home
Swimming pool?	Yes No
Trampoline?	Yes No
Burglar alarm?
Sprinkler system?
Kerosene, wood or oil stove?	Yes No
Dog?	Yes No
Computer?	Yes No
Livestock?	Yes No
Unusual/exotic pets?	Yes No

Is Your Home Located
Within 1,000 feet of a fire hydrant?	Yes No
Within 5 miles of a firestation?	Yes No
On a hillside?	Yes No
Close to a body of water or susceptible to flooding?	Yes No

General Questions
Year home built:
Number of families living in the home:
What part of the year is the home occupied?
Heating and cooling system:
What term best describes your kitchen?
Is business conducted on the premises?	Yes No
Does anyone in your home smoke?	Yes No
Did you experience any loss or claims in the last 5 years?	Yes No

Protective Devices
Smoke detectors?	Yes No
Fire extinguishers?	Yes No
Fire alarm?
Deadbolt locks?	Yes No

Additional Information
Gated community with a security guard:	Yes No
Neighborhood watch program:	Yes No
Senior citizen discount (all occupants age 55+):	Yes No

Homeowners Coverages And Deductibles
Dwelling Coverage A - Replacement cost of your home:
Other structure Coverage B - Typically 10% of coverage A:
Personal property / contents Coverage C - Typically 50% of coverage A:
Loss of use of your home Coverage D - Typically 20% of coverage A:
Personal liability:
Medical payments:
Desired deductible:

Additional Data
Quote requested within:	24 Hrs 48 Hrs 72 Hrs
Do you want an umbrella quote:

Optional Questions
If you have a collection that is anything of value such as Coins, Stamps, Art, etc., specify the approximate value/limits:
If you have any furs or jewelry, please specify the approximate value/limits:
Do you have any special interest or hobbies that could be considered a home based business?	Yes No
Do you travel?	Yes No
Do you travel outside of the United States?	Yes No
When you travel, do you bring valuables such as watches, jewelry or furs with you?	Yes No
Do you buy things while traveling and want to know that they are immediately insured under your policy?	Yes No
If your home were destroyed, would you want to rebuild it in the same location?	Yes No
Do you have / want backup of sewers and drain coverage?	Yes No