Homeowner's Insurance Application | Newman's Insurance Place

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Homeowner’s Insurance Applicationnewmansins2017-09-18T21:54:01-04:00

Name: *

First

Last

Address: *

Address Line 1

Address Line 2

City

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 ($): *

Other Structures ($): *

Liability ($): *

Optional Coverage

Water Backup (Highly Recommended): *

Coverages

Earthquake
Refrigerator Contents

Coverage Not Listed:

Number of Acres: *

Farming or Livestock on the premises: *

Yes
No

General Information

Foundation: *

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: *

Central Air Conditioning: *

Yes
No

Any other supplemental heat? *

Yes
No

If yes, what type? *

Number of Stories: *

Square Footage: *

Substructure: *

Any Specialty Rooms (laundry, great room, study, etc)? *

Finished Basement? *

Yes
No

If yes, square footage of finshed area: *

Number of Porches: *

Size of Porches:

Number of Decks: *

Size of Decks:

Number of Fire Places: *

Number of Baths (Full and Half): *

Attached Garage? *

Yes
No

If Yes, Number of Cars: *

Additional Comments

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