A.D. DERN INSURANCE AGENCY, INC.

HOME, CONDO, RENTERS, MOBILE &

FIRE DWELLING INSURANCE QUOTE FORM

CUSTOMER INFORMATION *required fields in red

    
*Email Address
*Home Telephone
*Applicant's First Name
Cell Telephone

Mailing Address

Business Telephone
City State Zip
Fax Telephone

*Type of Residence
   
     
Number of years / months have you owned this property ?. . . .

CURRENT INSURANCE INFORMATION - See Privacy Statement

Company Name

COVERAGE
Renewal Date
B. Other Structures
Premium
C. Personal Property
D. Loss of Use
Home Occupied By
E. Personal Liability
Pool or Spa?
F. Medical Payments
# of Occupants in Home?
Deductible
Business at Home?
List Add'l Items Below
  
Own a Dog?
Breed
Other Animals?
Types

Credits Available for Home Insurance
Alarm System? Monitored?
Sprinkler System in Ceiling?
Neighborhood Watch Program?
Smoke Alarms in Home?
Deadbolt Locks?
Fire Extinguishers in Home?
Auto Insurance with Same Carrier?
Senior Citizen Credit?
Non - Smokers Credit?
Gated Community Credit?
Claim Free for 5 Years?
Security Building Credit?

HOME DESCRIPTION & DETAIL

Year Home Built

Square Foot of Living Area
Foundation Type
 
SAFETY UPDATING OF HOME SYSTEMS
Foundation Bolted
Basement
# of Building Units
 
Year
Extent of Updating
# of Stories
Roof Type
Roof Year
 
# of Garages
Garage Attached
# of Carports
  Plumbing
# of Bedrooms
# of Baths
Bath Floors
  Heating
Entry Floor
Kitchen Flr
Counter Tops
  Roof
Air Conditioning
Fireplaces
Wet Bar
  Paint
Porch
Redwood Deck Sq Ft Area
Patio Cover Sq Ft Area
  EQ Retrofitting
What is the Style of your home? . . . . How would you rate the Construction Quality of your Home?

Any farm animals / activities at home or on grounds? yes no . . If Yes, Please list & describe
Are there any detached structures? yes no . . If yes, Please give size & describe use


5 YEAR CLAIM HISTORY
Claim
Date of Claim
Type of Claim

Description of Claim
Amount of Claim Paid
1
2
3
4

Ever been canceled or non-renewed in past 5 yrs? yes no If yes, please explain

Have you ever had a Fire Claim in your life time? yes no If yes, please explain
Does Home have any existing or unrepaired damage? If yes, Please list & describe

PERSONAL INFORMATION - See Privacy Statement
 
Owners Name

Birthdate
mm/dd/year

SS #
no dashes
Filed Bankruptcy past 7 yrs
Occupation
Employer Name
Yrs / Mos with employer
1
2
/
3
/
4
/

ADDITIONAL NOTES



I/We acknowledge submission of this information is to receive a price quote for insurance, and that NO INSURANCE IS INFORCE until a completed and signed application with payment has been accepted by A.D. Dern Insurance Agency, Inc. and according to any specific Insurance Company requirements.

I agree to the above terms