Insurance House Specialty Homeowner Quote Sheet
This is a non-binding indication worksheet subject to a signed application and approval by our underwriting department.
No Coverage is bound until confirmed by underwriting.
Today's Date:
Agent: Producer Code:
Phone: Email:
Proposed Effective Date: Policy Term:
Customer’s Name(s): DOB:
Occupation: If Retired – Prior Occupation:
SSN: Phone #:
Risk Address:
Mailing Address:
Policy Form Requested
Construction Type: Protection Class: Year Built:
# of Stories: # of Families: Floor of Condo Unit:
Square Footage: Minimum Nights Stay: Length of Vacancy:
System Updates:
Electric – YR Heating – YR
Plumbing – YR Roof – YR
Roof Type:
Electrical/Heating/Plumbing Types (Select all that apply):
Coverage Requested:
Dwelling $
Other Structures: $
Personal Property: $
Loss of Use/Fair Rental: $
Liability: $
Medical Payments: $
Deductible: AOP Wind
Additional Coverage
Water Back up
Extended Repl. Cost
Other Coverage Requested:
Losses: List all Losses for Insured(Within 5 years)
Date Type Of Loss Amount Paid Open/Closed/Subro
Pool Fenced/Screened Animals with Bite History Business on premises
Arson/Bankruptcy/Foreclosure/Fraud/Repossession/Other crime related property loss within the last 5 years
Builders Risk/ Course of Construction or Vacant
1) Are renovations/const being completed by insured?
2) Type of Renovations:
3) Value of Renovations/Completed Construction: $
Is Customer Requesting: