Name
Property Street
Property City
Property State
Property Zip Code
Daytime Telephone #
E-mail Address

Insurance Coverages

 

Replacement cost of your  home not including the land
Personal Liability	$1,000,000 $500,000 $400,000 $300,000 $200,000 $100,000
Medical Payments	$5,000 $4,000 $3,000 $2,000 $1,000
Earthquake Coverage	Yes No
Deductible	$250 $500 $1,000 $2,500

Home Information

 

What year was your home built
If home is older than 20 years please advise the date the following items were updated and if it was full or partial.	Plumbing None Full Partial Year Heating None Full Partial Year Electrical None Full Partial Year Roofing None Full Partial Year
Is this your primary residence?	Select Yes No
# of families	1 2 3 4
# of units rented to others	0 1 2 3 4
Construction type	Select Frame Masonry Brick Veneer Aluminum Siding Vinyl Siding

	Please Check All That Apply
	Smoke Detectors
	Central Fire Alarm
	Central Burglar Alarm
	Own a dog? If yes what breed?
	Wood Stove? If yes, when was it inspected by fire dept.
	Do you have a pool?
	If you have a pool does it have a diving board?
	Do you have a trampoline?
	Does your home have an underground fuel tank?
	Do either you or your spouse smoke?
	Are either you or your spouse over the age of 55 and stay at home?
	Do you currently have a homeowners policy?
	Have you had any claims in the past 3 years?
	If you had any claims please describe with amount actually paid.
	Do you have an active auto policy with Commerce Insurance?

Comments

 

Any additional comments or insurance coverages?

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