HOMEOWNERS QUOTATION FORM Today's Date: QUOTE TAKER'S NAME: Email Address: What is your First Name: What is your Last Name: What is your Home Phone Number: Fax Number: What is your Property Address: City: County: Zip Code: What kind of Home it is: Single Family Town House Condo or Duplex Do you Currently have Insurance: Yes No If Yes, with which Company: Expiration Date: Current Premium:   What is your Current Building Coverage amount: What is the Building Constructions Type: YR Build: Updates, if over 50 Years old: Wiring Roof Plumbing Heating What is the square Footage of your Home: Number of Stories: Number of Bedrooms: Number of Bathrooms: Number of Half-Bathrooms: Car Garage: Yes No Number of Cars:  IF NO. Is there a Carport: Yes No Is the Garage attached to your Home: Yes No If Not, is it Built-in: Yes No Do you have Swimming Pool: Yes No Is it Fanced: Yes No Is it In-ground: Yes No Do you have an open Patio or is it Screened: Is an Appraisal available: Yes No Have you Reported any Claims in the past 3 Years: Yes No If Yes, please describe loss: Is your house occupied by: You OR Tenant Type of Coverage Desired: Home Flood Wind Central Alarm: Yes No If Yes, which type: Burglar Smoke Fire Do you have Alarm Certificate: Yes No If Yes, please Fax us a copy. FLOOD INSURANCE DO YOU HAVE AN ELEVATION CERTIFICATE OR COPY OF YOUR CURRENT FLOOD POLICY: Yes No IF YES, PLEASE FAX US A COPY ST 954-735-8889 NOTES