|
INSURED INFORMATION
(please fill in the following information to the best of your ability in order to receive the most accurate quote possible.) |
|
Name: |
|
|
Date of Birth (MM/DD/YYYY) |
|
|
SSN#: |
|
|
Occupation: |
|
|
Mailing Address (if different than property address): |
|
|
Contact Preference? |
Telephone
Email
|
|
Primary Contact Number: |
|
|
Alternate Contact Number: |
|
|
Email Address: |
|
|
HOME INFORMATION: |
|
Property Address: |
|
|
Closing Date: (mm/dd/yy) |
|
|
Type of Construction? |
Brick
Frame
|
|
Square Footage of Living Area: |
|
|
Type of Heat: |
|
|
Number of Stories: |
|
|
Number of Families |
Single Family House
Two Family House
|
|
Number of Rooms |
|
|
Number of Full & Half Baths: |
|
|
Fireplace? |
Yes
No
|
|
If Yes, How Many? |
|
|
Garage? |
Yes, Detached
Yes, Attached
No
|
|
If Yes, How Many Cars? |
|
|
Basement? |
Yes, Finished
Yes, Unfinished
No
|
|
If Finished, Standard or Custom? |
|
|
Year Built? |
|
|
Renovations/Updates Date: (if applicable) |
|
|
# of Claims or Losses? |
|
|
Fenced Pool? |
Yes, Above Ground
Yes, Inground
No
|
|
Exotic Pets? |
Yes
No
|
|
If Yes, What Kind? |
|
|
Burglar Alarm? |
Yes
No
|
|
CURRENT INSURANCE?
(if you currently have another auto insurance policy elsewhere, please answer the following questions) |
|
Name of current carrier? |
|
|
Expiration Date of current policy? (mm/dd/yy) |
|
|
Dwelling Coverage Amount: |
|
|
Liability: |
|
|
How Did You Hear About DMAS? |
|
|
|
