PDF Archive

Fact Finder
• For no-obligation quotes, please fill in as many fields as possible and fax this form to your agent.
• For accurate comparative quotes, include your current insurance policies’ “Declarations” pages in the fax.
Name __________________________________________ Email _________________________________________
Spouse/Civil Union Partner Name ____________________________________ Years at current address ________ County ___________________
Street Address ___________________________________ City _______________________________ State _________ Zip __________________
Home Phone ____________________ Cell Phone ___________________ I prefer to be contacted where/what time _______________________
Work Phone ____________________ Employer _____________________________________________ Years with current employer _________
Occupation _______________________ Full time or Part time __________

Auto Insurance
Current Auto Insurance Company ________________________________________ Policy # _________________________ Years with Carrier ___________
Current Premium___________________ Auto Policy Expiration Date _________________ Who owns the vehicles? ________________________________
Current Coverages

r25/50 r50/100 r100/300 r250/500

Permission to order reports? Yes / No

Current Collision Deductible

r250 r500 r1000

New Policy Start Date ________________________
Drivers in Household

Name

Date of Birth

Driver’s License Number

Gender
M/F

Marital
Status

Number
of Tickets

Number
of Claims

Age first
Licensed

All Vehicles in Household
Year

Make

Model

Primary Driver

Where parked at home (garage, Miles one way to
driveway, on street, etc.)
Work / School

Own/
Lease

Full Covg /
Liability

Alarm
Y/N

Homeowners Insurance
I want to insure a:

r Home

r Condo or Townhome ( r Center or r End Unit )

r Renters

r Other________________________________

Current Insurance Company_______________________________________________ Policy #__________________________ Years with Carrier____________
Current Premium___________________ Homeowners Policy Expiration Date________________ Who owns the home?_____________________________
Current Dwelling Amt__________________ Market Value________________
Liability

r 100K r 300K r 500K r 1M

Deductible

r 250 r 500 r 1000
# of Families__________

Do you Escrow?

Square Feet (above ground)___________________

Year Built___________

Style of Home_ _______________________________

Age of Roof__________________________________

dead bolts?

Exterior Type_ ________________________________

Age of Electrical_ _____________________________

fire extinguisher?

Number of baths: Full_________ Half_________

Age of Plumbing______________________________

smoke detectors?

Type of Heating_______________________________

Age of Heating_______________________________

central fire alarm?

Location of Oil Tank___________________________

Miles to Fire Department______________________

central burglar alarm?

Claim in the last 5 years_______________________

Number of Feet to Fire Hydrant________________

local burglar alarm?

Value of Contents (renters only)________________

Number of Fireplaces__________________________

trampoline?

r Yes r No

Do you have:

r Yes
r Yes
r Yes
r Yes
r Yes
r Yes
r Yes

r No
r No
r No
r No
r No
r No
r No

Value of “special” property such as jewelry, fine art, or expensive computer equipment_______________________ Any animals?_________________

Please Note Any Claims /Accidents / Special Instructions Here: