EmailMeForm
Basic Information
Phone
*
Email
*
How many Property Owners?
Please select
1
2
Property Owner #1: Name
*
First
MI
Last
Property Owner #1: Date of Birth
Month / Day / Year
Property Owner #2: Name
First
MI
Last
Property Owner #2: Date of Birth
Month / Day / Year
Marital Status
Single
Married
Divorced
Widowed
Property Details
Home purchase date
Month / Day / Year
Is this home new construction?
Yes
No
If yes, what is the square footage excluding the basement?
If yes, what is the estimated completion date?
Month / Day / Year
Property Address
Street Address
City
State / Province / Region
Postal / Zip Code
Is your property address the same as your mailing address?
Yes
No
If No, What is your mailing address?
Street Address
City
State / Province / Region
Postal / Zip Code
Number of Household Residents
Please select
1
2
3
4
5
6
7
8
9
10
Property Status
Owner Occupied
Tenant Occupied
Rental Property
Vacant
Dwelling Style
Colonial
Ranch
Split Level
Contemporary
Cape Cod
Bungalow
Condo
Other
Home exterior
Siding
Brick
Wood
Other
Check all that apply
Trampoline on premises
Wood Burning Stove
Deck
Outbuildings (Shed, Pool House)
Smoker in Household
Swimming Pool
Security System
If yes to swimming pool, is it above ground or inground?
Do you have a garage?
Yes
No
If so, what type of garage? (Attached, Detached, 1 Car, 2 Car etc.)
Do you own a dog (s)?
Yes
No
If so, what breed (s)?
Do you have a basement?
Yes
No
If so, is it finished?
Roof Installation Year?
*
Roof Material
Composite/Asphalt
Metal
Woodshake
Tile/Slate
Other
Age of Furnace
If new purchase, what is the closing date?
Is there any existing damage, needed repairs or Liability hazards to the roof, Structure, Chimney, Foundation, Premises or Other Structures?
Is the dwelling located within 1000 ft from a fire hydrant?
Yes
No
Is the primary responding fire department within 5 miles from the dwelling?
Yes
No
Do you have any Collectibles / Jewelry / Guns / Precious metals needing to be scheduled?
Yes
No
If Yes, what are they?
Insurance History
Any Homeowner claims in last 5 years?
Yes
No
If Yes, please explain
If currently insured, when does your current insurance policy expire?
Month / Day / Year
Interested in adding Umbrella Insurance? Umbrella insurance is extra insurance that provides protection beyond existing limits and coverages of other policies.
Yes
No
Can we help you save by bundling on any of the following insurance products we offer:
Home
Auto
Condo
Renters
Motorcycle
Boats
ATVs
Business
Life
One Last Thing...
How Did You Hear About Us?
Word of Mouth / Referral
Social Media
Online Search
Mail
Other
Who referred you to Baehr Insurance Agency?
Preferred Contact Method
Phone
Email
Text
