May 18, 2012
Casswood Insurance Agency, Ltd.
Homeowner's Quote
 
 Policy Holder
  Contact Name *
  Name of Policy Holder(s) *
  Policyholder Name(s) continued
  Status? * Married
Partnered
Single
Divorced
Widowed
None
  Date of Birth (MM/DD/YYYY) *
  Social Security Number
  Email *
  Phone Number *
 
 Property Location
  Address *
  City *
  State *
  Zip *
  County *
 
 Current Insurance Information
  Company Name
  Current Annual Premium
  Expiration Date / Desired Effective Date *
  Deductible Desired *
  Amount of Liability Coverage *
  Earthquake Coverage Desired? * Yes  No
  Flood insurance required or desired? * Yes  No
  Have you filed for bankruptcy within the past 7 years? Yes  No
 
 Dwelling Information
  Is this residence a?
  Current or Required Property Limit
  Square Footage
  Year Constructed
  How Many Floors?
  Type of Construction
  Garage?
  Other Features
  (check all that apply)		 Dead Bolts
Smoke Detectors
Fire Extinguisher
Central Station Fire Alarm
Central Station Burglar Alarm
Home Located within 5 miles of Fire Station
Home Located within 1000 feet of a Fire Hydrant
Swimming Pool
Swimming Pool is Fenced
Trampoline
Home located within City Limits
 
 Claims
   List any claims in past 3 years:
  Date of Claim Amount Paid Claim Type Description
1.
2.
3.
 
 Personal Property
   Estimated value of your personal property: (please note that it may be necessary to provide receipts, appraisals or a copy of your current policy to substantiate these values.)
  Jewelry & Watches
  Computer & Other Electronic Items
  You may wish to includes items such as flat panel TV's.
  Furs
  Silver
  Firearms
  Stamp and Coin Collections
  Fine Arts and Breakable Items
  * indicates required fields
 
Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.
 
© 2010 All Rights Reserved Casswood Insurance Agency, Ltd., New York - California, CA LIC 0C21643 (518) 373-8700 / (800) 972-2242
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