Home
Products
Auto Insurance
Business Insurance
Commercial Insurance
Farm Insurance
Homeowners Insurance
Life Insurance
Get Quote
Automobile Insurance Application
Boat Insurance Application
Camper/RV Insurance Application
Motorcycle Insurance Application
ATV/4-Wheeler Insurance Application
Homeowner’s Insurance Application
Life Insurance Application
Health Insurance Application
Companies
About Us
Meet the Team
Blog
Contact Us
Directions
Questions?
Call us: (740) 775-1001
info@newmansinsuranceplace.com
Get a Quote
Questions?
Call us: (740) 775-1001
info@newmansinsuranceplace.com
Get a Quote
Home
Products
Auto Insurance
Business Insurance
Commercial Insurance
Farm Insurance
Homeowners Insurance
Life Insurance
Get Quote
Automobile Insurance Application
Boat Insurance Application
Camper/RV Insurance Application
Motorcycle Insurance Application
ATV/4-Wheeler Insurance Application
Homeowner’s Insurance Application
Life Insurance Application
Health Insurance Application
Companies
About Us
Meet the Team
Blog
Contact Us
Directions
Homeowner’s Insurance Application
Home
Applications
Homeowner’s Insurance Application
Name:
*
First
Last
Address:
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone:
*
Email:
*
Email
Confirm Email
Occupation:
*
Birthdate:
*
Social Security Number:
*
County:
*
Township:
*
Do you currently have Homeowner's Insurance?
*
Yes
No
If Yes, what company?
*
Are you a AAA member?
*
Yes
No
Have you ever had a cancellation/non-renewal/lapse in coverage?
*
Yes
No
If Yes, explain:
*
Have you had any losses in the last 5 years?
*
Yes
No
If yes, details and amount
*
Do you have a swimming pool?
*
Yes
No
Do you have a dog or any exotic animals?
*
Yes
No
If yes, what breed or kind?
*
Has it ever bitten?
*
Yes
No
Is this a new home purchase?
*
Yes
No
If yes, purchase price and date?
*
Coverage
Dwelling ($):
*
Personal Property ($):
*
Medical Payments ($):
*
$1,000
$2,000
$5,000
Other Structures ($):
*
Liability ($):
*
$100,000
$300,000
$500,000
Optional Coverage
Water Backup (Highly Recommended):
*
$5,000
$10,000
$20,000
Coverages
Earthquake
Refrigerator Contents
Coverage Not Listed:
Number of Acres:
*
Farming or Livestock on the premises:
*
Yes
No
General Information
Foundation:
*
Frame
Brick
Mobile
Modular/Doublewide
Paying Real Estate or Mobile Home Taxes?
*
Yes
No
Is there a fire hydrant within 1,000 feet of your home?
*
Yes
No
Is there are fire department within 5 miles of your home?
*
Yes
No
Type of Heat:
*
Heat Last Updated:
Type of Roof:
*
Roof Last Updated:
Wiring Amp:
*
Breaker
Fuse
Wiring Amp Last Updated:
Plumbing:
*
PVC
Copper
Galvanized
Central Air Conditioning:
*
Yes
No
Any other supplemental heat?
*
Yes
No
If yes, what type?
*
Number of Stories:
*
Square Footage:
*
Substructure:
*
Crawlspace
Basement
Slab
Any Specialty Rooms (laundry, great room, study, etc)?
*
Finished Basement?
*
Yes
No
If yes, square footage of finshed area:
*
Number of Porches:
*
0
1
2
3
4
Size of Porches:
Number of Decks:
*
0
1
2
3
4
Size of Decks:
Number of Fire Places:
*
0
1
2
3
4
Number of Baths (Full and Half):
*
Attached Garage?
*
Yes
No
If Yes, Number of Cars:
*
1
2
3
4
Additional Comments
Additional Comments
Website
Submit