Home Insurance Site built

Name of person completing this form. Include email, company name, if applicable and phone number*

Is this a course of construction policy quote request?

Yes

No

Name and Address of Contractor if applicable

DWELLING STRUCTURE TYPE

Please select all boxes that apply*

Primary Home (not a manufactured home)

Seasonal / Secondary Home (not manufactured home)

Vacation Rental listed as vacation rental

Are you or have you been insured in the last year?

Yes. I am currently insured

I do not have insurance it lapsed/cancelled

This is a new home purchase. Never insurance before

Name of Current or most recent insurance carrier*

The expiration date of current or most recent policy

Do you have more than one home at this location?*

Yes

No

Property address where dwelling is located*

Street Address City State ZIP Code

Please tell us about the second home

OWNER(S) NAMES AS IT APPEARS ON TITLE

How many names on title?*

1. First Name*

First Last

Date of birth*

Email*

Phone Number required*

Type of phone

Occupation*

Second Name

First Last

Date of birth

Occupation

OUTBUILDINGS - DETACHED GARAGE, BARNS

Describe all other dwelling

Please include year built, square footage, number of stories. We may have additional questions later.

Would you like to add any comments or remarks at this point?

Yes

No

Comments or Remarks

PRIMARY DWELLING STRUCTURE INFO.

Year of construction

Number of Stories

Siding Material type:

Occupancy use*

Primary

Secondary or seasonal

Rented to tenant full time

Vacation rental to others

Hobby Farm

Equine Ranch

Other Farm or Ranch Commercial

Winery / Vineyard

What is the name of your responding Fire Department?

If you do not know we will research this for you.

Check all that apply

Hard wired smoke alarms

Battery functioning smoke alarms

Fire Extinguisher

Dead Bolts

Central Station Fire alarm

Square Footage

Garage type (if none state "none"

What is the approximate distance to a fire hydrant?

Estimated distance to the closest fire department

Any claims in the last 5 years?

Provide estimated date of claim, claim type and amount paid

Do you have items of high value that you want to schedule?

Yes

No

Do not understand and would like to discuss

Examples would be jewelry, paintings, collectibles

If this is for an escrow closing do you want to provide the lender and title information now?

Yes

No

SCHEDULED PERSONAL PROPERTY

Would you like to list items that need to be scheduled on your home insurane policy?

No items to schedule

Yes I want to list them now

Later but yes, I do have items to schedule

Name of item, value and date last appraised or purchased

Notes, Questions or Comments

Title Company Information

Escrow Officer's name

First Last

Title Company's Phone Number

Fax number to title company:

Escrow Officer's Email Address (not required)

Title Company's Name

First Last

Title Companies Address (at the minimum provide City)

Street Address City State ZIP Code

Escrow number if you have it (not required)

Current Mailing Address if different than dwelling address

Street Address City State ZIP Code

Liability limit and Deductible

Medical (required)

Comprehensive Personal Liability or Owner Landlord & Tenant Liab.

If owner occupied you must have CPL. If tenant occupied you must have OL&T. If Tenant occupied this will be quoted as a DP3 / Dwelling Fire Policy. In some instances we will quote a DP1. All the replacement forms type will be discussed with you later.

Personal Umbrella limit:

Deductible (this is your self-insuring limit)

The deductible applies to Coverage A: Dwelling, Coverage B: Outbuildings and detached structures and Coverage C: Personal Property.

Are there any "other" home/dwelling claims?

Yes

No

List dates, type and amount of loss for each

Are any of the dogs mixed with or are pit bull, doberman, roteweiler aikia, wolf or an animal with a prior bite history?

Yes

No

Quote Homeowners from Athena Site

DWELLING STRUCTURE TYPE

OWNER(S) NAMES AS IT APPEARS ON TITLE

OUTBUILDINGS - DETACHED GARAGE, BARNS

PRIMARY DWELLING STRUCTURE INFO.

SCHEDULED PERSONAL PROPERTY

Title Company Information

Liability limit and Deductible

VACATION RENTAL SUPPLEMENTAL QUESTIONS

Vacation Post Stay Inspections