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DEMPSTER INSURANCE AGENCY LLC.
HOMEOWNERS QUOTE INFORMATION
Name:
*
Address:
*
Phone #:
*
###
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###
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####
Email Address:
DOB:
*
Prior Carrier:
Policy #:
Exp. Date:
Prior Dwelling Coverage:
Deductible:
Prior Premium:
Prev. Liab:
Prev. Med:
Home Information
Name on deed/title of the house:
Type:
Frame
Brick
Exterior: (Brick, vinyl siding, shingle, etc.)
Mortgage?
Yes
No
Year built:
Sq. Footage:
No. stories:
No. baths:
Date purchased:
Finished basement?
Yes
No
Sq. ft. of basement:
Fireplace?
Yes
No
Fuse Box or Circuit Breakers?
Fuse box
Circuit breakers
Electrical- Amperage Service (# of Amps)
Heating source:
Gas
Electric
Other
Wood/Corn Burner? If yes, make and model:
Central air?
Yes
No
Garage?
Yes
No
If yes, is the garage attached or detached,and # of cars:
Deck? YES OR NO. If yes, sq. footage:
Porch? YES OR NO. If yes, OPEN OR CLOSED, and sq. footage:
Interior Walls:
Drywall
Plaster
Floor coverings:
Carpet
Vinyl
Wood
Tile
Ceiling Material:
Drywall
Plaster
Updated roof, electrical, plumbing, heating or A/C? If so, list years:
Any Pets? If yes, type and breed:
Swimming pool?
Yes
No
Trampoline?
Yes
No
Ever filed for bankruptcy? If yes, when:
Optional coverages desired?
Mine subsidence
Yes
No
Earthquake
Yes
No
Backup Water/Sewer
Yes
No
Scheduled Property YES OR NO, if YES, list the type of items (jewelry, china, etc.), value and description (bill of sale or appraisal for each item)
Protective Devices if any:
Central alarm: fire/burglary
Sprinkler system: full/partial
Deadbolt locks: front/back
Fire extinguisher
Smoke alarm
Other
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