Walk Insurance Agency - Home Quote
 
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Walk Insurance Agency, Inc - Home Quote


PLEASE NOTE: Required fields are in red.
Fill these fields out to obtain accurate pricing, any indication of rates provided are subject to underwriting, verification of information and acceptance by the Insurance Company
(see disclaimer notes and information about this form.)

HOME OWNER INFORMATION - * = Required Fields

*Name:
*S.S #:
*D.O.B. (MM/DD/YY)
Status:
*Occupation:
*Employer:

 DAYTIME / EVENING PHONE NUMBERS

Home Phone:
Work Phone:
Cell Phone:
Best Time To Call:
*E-Mail:


 ADDRESS INFORMATION

*Address:
*City:
*County:
State:
*Zip:
Directions:
Previous Address
If Less than 1 Yr.:


HOME INSURANCE -  UNDERWRITING INFORMATION

Policy Type : # of Units :
*Year Built: *Ground Floor Sq.Ft.:
Total Rooms: LeinHolder:
*Year Purchased: Purchase Price:
Yr.Last plumbing update: Drains:
Electrical System: Yr. Last Update:
Central Alarm: Air Conditioning:
Heating: Yr. Last Update:
Wood Burning Stove: # of Fireplaces:
# of Chimneys: # of Hearths:
Garage: # of Car Garage:
Swimming Pool: Pool Fenced In:
Size of Decks (sq.ft.): # of Bathrooms
2 HalfBaths=1 Full Bath:
Mine Subidence Area: Flood Area:
Responding Fire Dept.: Distance to Fire Dept.:
Distance to Hydrant: # of Corners on the home:
Any bathrooms adjoin bedrooms: Any Hardwood, Slate, Marble or Quarry Tile Floors(Over 70 sq.ft.):
Any Stained, Varnished Woodwork throughout including Baseboards, Windowsills or doors: Any Brick or Stone Exterior Walls:
# of Aluminum Awnings: # of Canvas Awnings:
Any Hinged Shutters: Trampoline on Premises:
Fences: Linear Feet of Fence:

STORIES CONSTRUCTION FOUNDATION ROOF
1-Story 
1 1/2-Story 
2-Story 
Split Level 
Bi-Level 
Tri-Level 
Frame or Stucco 
Masonry
Mostly Masonry & Frame  
Mostly Frame & Masonry 		Full Basement 
Partial Basement 
Basement Type 

If Partial - enter % 

If Partial - enter sq.ft. finished 

Crawl Space 
Slab  		Asphalt Shingle 
Wood Shingle 
Tile or Slate 
Other 
Age of Roof (Yrs.)  

BUILT-INS (Check All That Apply)
Whole House Fan
Roof Exhaust Fan
Central Vacuum
Counter Top Range
Oven
Dish Washer
Range Hood 		Trash Compactor
Wet Bar
Garbage Disposal
Microwave
Kitchenette
Water Purifier
Water Softener 		Sky Lights
Hot Tub
Jetted Tub
Sauna
Bath Room Heater
Electronic Ait Filter
Fire Extinguisher 		Smoke Alarms
Alarm Systems
Carbon Monoxcide Detector
Deadbolts on ALL outside Doors
# of Ceiling Fans # Elec.Garage Door Openers

SPECIALTY ROOMS (Check All That Apply)
Den
Excerise Room
Library
Office
Sun Room
Study
 Rec Room
Family Room
(Addition to Living Room)
Great Room
(Over 300 sq.ft.)
 Formal Dining Room
(not dining area)
Large Foyer
(Over 70 sq.ft.)
Laundry Room
(Over 70 sq.ft.)
 Other Specialty Rooms

Prior Losses Past 5 Yrs.:
If any Business is being conducted on the premises, please describe:
Bankruptcy Ever Filed:


CURRENT INSURANCE INFORMATION

Insurance Carrier:
How Long:
Expires (MM/DD/YY):
Deductible:
Current Premium / Period (Monthly or Annual):

Current Insured Values
Dwelling :
Personal Liability :
Personal Property :
Medical Payments :
Personal Injury :
Scheduled Property :
Flood Coverage :
Other Coverage :
(Business/Hobby/Farm)


Other Coverage or Special Needs


Coverage & Values Requested
Earth Quake Coverage: Earth Quake Deductible:
Sewer/Drain Back Up: Back Up Deductible:
Replacement Cost on Home:
Replacement Cost on Contents:
Liability Limits:
Medical Limits:
Scheduled Personal Property (Jewelry, Guns, Furs, Cameras, Collectables, Sporting Goods, Etc.)
Itemize and include dollar value of each item.