Oliver & Associates: Property Insurance Quote

Applicant Information:

*Applicant's Full Legal Name:

*Applicant's SSN#:

*Co-Applicant's SSN#:

*Has Applicant or Co-Applicant ever filed for Bankruptcy? Yes No

*Is this an investment property and/or do you intend to rent this property? Yes No

If so, will the property be deeded to Personal Business

your personal name or a business name? Name of Business:

*Home Telephone #:

Alternative Telephone #:

Work Telephone #:

Email Address:

*Address:

*City, State, Zip Code:

Current Carrier Information:

*Current Insurance Company:

Current Expiration Date:

*Prior Claims (Last 5 Years):

Yes No

If Yes, please explain:

Request Liability & Building Value Information:

*Liability Limit:

Umbrella Liability:

*Building's Current

Insured Value:

Optional Coverages:

Identity Theft Protection Water & Sewer Backup Earthquake Protection

Flood Ordinance or Law Scheduled Personal Property (ie: Jewelry, Guns, Collectables.): Value:

Mortgagee/Loss Payee:

Mortgagee/Loss Payee Name:

Mortgagee/Loss Payee Address:

Will this policy be escrowed? :

Yes No

Is this a new purchase?

Yes No

If so, when is the scheduled closing date? (mm / dd / yyyy)

Is the property's address different from the one you entered above?

Yes No

If so, what is the complete address?

Address:

City, State, Zip Code:

Home Information (Only list information about the property you want to insure):

Year Built:
Number of Bathrooms: Number of Bedrooms:
Does your home have the following rooms?	Living Room Dining Room Family Room
Does your home have one of the following protection devices?:	Dead Bolts Smoke Alarms Security System
How many fireplaces does the homes have?
Do you have a woodstove?
What type of woodstove?	Freestanding Insert Separate Chimney
Distance to Fire Hydrant:
Distance to Fire House:
Number of Stories:
Square Footage:
Have there been any updates to the building?:	Yes No If Yes, please list what was completed and when:
Deck Square Footage:
Porch Square Footage:	Open Closed
Construction Type:	Frame Brick/Masonry Stucco Other
Do you have an attached garage, detached garage, or carport?:	One Car Two Car
What type of heat does your home have?
Do you have central air?
Do you have any animals?	Yes No If so, what type and how many?
Foundation Type:

Additional Information:

If you would like to include any additional information, please list it here.