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Home Insurance Form

As an independent agent, we represent a number of companies that offer homeowner's insurance. The following are some basic questions that would allow us to work up a quote for you with our company that is most competitive for your particular property. Please complete as many fields as possible as the more complete the information, the best chance we have to find the best available coverage for the best available price.

Your Personal Information
Your Name:
E-Mail:
Mailing Address:
City:
State:
Zip:
Home Phone:
Work:
Cell Phone:
How would you like us to contact you?:
Is Your Home Address the Same as Above? Yes    If No, please fill out the below.
Home Address:
City:
State:
Zip:
Date Of Birth:
Driver License #
Social Security #
Marital Status:
If Married, Your Spouse Information:
Spouse Date Of Birth:
Spouse Driver License #
Spouse Social Security #
Information on Your Home
Is this a New Purchase?:Yes    No
If Yes
If Yes, Purchase Price?:
If Yes, Expected Closing Date?:
If No, Current Insurance Carrier
If No, Renewal Date
If No, Currently Covering Home For?
Coverage Desired:
Liability Limits Requested
Deductible Requested
Property being covered is your:
Replacement Cost:
Year Built:
Construction:
Square Footage Estimate:
Number of Bedrooms:
Number of Bathrooms:
Renovation Credits May Be Possible:
Age of Roof:
Age of Electric:
Age of Plumbing:
Age of Heating System:
Do You have (please check all that apply) Woodstoves
Any Business Conducted from this Property
Trampolines
Swimming Pool
Account Credits are often available with multiple policies with the same company. Should we contact you about:Auto Insurance
Boats
ATV's
Umbrella
Comments/Instructions:
*

Thank you for taking the time to complete this form

properties adirondack  adirondack real estate
S. Curtis Hayes, Inc. Insurance and Real Estate
20 Broadway, P.O. Box 1325, Saranac Lake, NY 12983
518-891-2020 · 518-891-2990 FAX
E-Mail: S. Curtis Hayes, Inc.

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