 |
|
For: Tom Agent
Type: Homeowner's |
| |
|
|
|
Contact Information
|
| |
|
|
|
Name: |
Jim Customer |
Email: |
jimc@emailforyou.com |
Address: |
123 Sample Lane |
Daytime Phone: |
(123) 234-0934 |
|
Anywhere, AL 90012 |
Evening Phone: |
(123) 234-4523 |
Best Time to Contact: |
Afternoon |
Fax: |
(123) 234-1245 |
| |
|
|
|
Addtional Comments: |
We need home insurance as soon possible. This is a new house purchase. |
|
|
|
|
Personal Information |
| |
|
|
|
Birthdate: |
10/22/71 |
Credit History: |
Good |
Time at current residence: |
more than 10 years |
Time at previous Add: |
3 years |
Social Security Number: |
123-45-6977 |
Gender: |
Male |
| |
|
|
|
| |
|
|
|
Insurance Information
|
| |
|
|
|
Currently Insured: |
Yes |
Continuously Insured: |
10+ years |
Current Company: |
Liberty Mutual |
Current Premium: |
$1,075 yearly |
Current Policy Expires: |
4/20/05 |
Time with Company: |
5+ years |
| |
|
|
|
Property Information
|
| |
|
|
|
Address: |
123 Sample Lane |
Type of Dwelling: |
Single Family Home |
|
Anywhere, AL 90012 |
New Purchase?: |
Yes |
County: |
Sample |
Number of Residents: |
4 |
Year Built: |
1994 |
Occupancy: |
Primary Residence |
Square Footage: |
3,100 |
Stories: |
2 |
Basement: |
76-100% Complete |
|
|
Bedrooms: |
4 |
Bathrooms: |
3 1/2 |
Heat Source: |
Electric |
Fireplaces: |
1 |
Garage: |
Attached - 2 cars |
Wooden Patios/Decks: |
1 |
Foundation Type: |
Basement |
|
|
Siding: |
Brick |
Roof Type: |
Asphalt |
| |
|
|
|
|
|
|
|
Home Features |
| |
|
|
|
Distance to Fire Station: |
less than 5 miles |
Distance to Fire Hydrant: |
500-1,000 feet |
Dog Type: |
None |
Smoker in the home?: |
No |
Upgrades in last ten year?: |
Yes |
|
|
Upgrade Details: |
Rewiring of electrical system, March 2003 |
Burglar Alarm: |
Yes |
Monitored Alarm: |
Yes |
Fire Alarm: |
Yes |
Fire Extinguishers: |
Yes |
Smoke Detectors: |
Yes |
Indoor Sprinklers: |
No |
Cathedral/Vaulted Ceilings: |
Yes |
Hardwood Floors: |
No |
Unfenced Pool: |
No |
Fenced-In Pool: |
Yes |
Hot Tub: |
No |
Tennis Courts : |
No |
Manned Security Station: |
No |
Deadbolts: |
Yes |
Enclosed Porch/Patio: |
Yes |
Central Heating/Air: |
Yes |
| |
|
|
|
|
Coverage Requested
|
| |
|
|
|
Dwelling: |
$300,000 |
Contents: |
$60,000 |
Liability: |
$300,000 |
Deductible: |
$500 |
Additional Coverage Requests: |
Sump Pump |
|
|
|
|
|
Claim History (Last Five Years)
|
| |
|
|
|
Type: Water |
Amount: $1500.00 |
Date: September 2003 |
|
| Details: Roof leaked for 1 month before it was noticed. |
| |
|
|
|
