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Homeowners Insurance Comprehensive Form
Duration = 5 minutes
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What is your first name?
What is your first name?
What is your last name?
What is your last name?
What is your full name?
What is your full name?
What is your preferred phone number?
What is your preferred phone number?
Email
Please enter your email.
Occupation & Employer
What is your occupation and employer name?
Date of Birth
Please enter your Date of Birth (MM/DD/YY):
Will anyone else be named on this quote?
Will anyone else be named on this quote?
Yes
No
Other Insured's Name
Please enter their name:
Other Insured's Occupation & Employer
Please enter their occupation and employer name:
Other Insured's Date of Birth
Please enter their Date of Birth (MM/DD/YY):
Property Address
Please enter the address of the location you would like a quote for.
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
New Purchase?
Are you in the process of purchasing this home?
Yes
No
Purchase Price
What is the purchase price?
Closing Date
What is the closing date? (MM/DD/YY)
Effective date
When do you need this coverage to start? (MM/DD/YY)
Major Renovation
Will you do a major renovation to this home shortly after you purchase it?
Yes
No
Major Renovation Current Home
Do you have plans to do a major renovation at this home?
Yes
No
Renovation Budget
What is the approximate budget for the renovation?
Renovation Time Frame
How long will the renovation take?
Less than 30 days
1 to 3 months
3 to 6 months
6 to 12 months
1 to 2 years
What is your current home address?
What is your current home address?
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Occupancy
Please select the occupancy of this property.
Primary residence
Secondary residence
Rented to others (long-term, short-term, or seasonal tenants)
Unoccupied
Vacant (No contents remain)
Under construction/renovation
Other
Please select the frequency of rentals for this home.
Please select the frequency of rentals for this home.
Long-Term/Annual Lease
One to Two Months per Year
Summer Rental Property/Weekly
One night to Monthly (Ie. AirBNB, Homeaway.com, etc...
Occupancy other
What is the occupancy of this home?
What is your primary home address?
What is your primary home address?
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Will there be a mortgage?
Will there be a mortgage?
Yes
No
What is the name of the bank providing the mortgage?
What is the name of the bank providing the mortgage?
Who is your contact at the bank?
Who is your contact at the bank?
What is the phone number for your contact at the bank?
What is the phone number for your contact at the bank?
What is the email address for your contact at the bank?
What is the email address for your contact at the bank?
Will the insurance premium be escrowed?
Will the insurance premium be escrowed?
Yes
No
Not sure
What is the name of your current insurance carrier?
What is the name of your current insurance carrier?
Is there a mortgage?
Is there a mortgage?
Yes
No
Please enter the bank name, if convenient.
Please enter the bank name, if convenient. (Ex. Bank of America NA, ISAOA ATIMA)
Please enter the bank address, if convenient.
Please enter the bank address, if convenient.
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Please enter the loan number, if convenient.
Please enter the loan number, if convenient.
Is the insurance premium being escrowed?
Is the insurance premium being escrowed?
Yes
No
Not sure
Trust or LLC
Is there a Trust, LLC or Limited Partnership involved in the ownership of this property?
Yes
No
Trust or LLC Name
Please enter the name of the Trust, LLC or Limited Partnership:
Alarm System
Is there an alarm system in this home?
Yes
No
Alarm System Components
Select the components of your alarm system.
Heat/Smoke detectors
Burglar motion sensors
Low temperature monitor
Water leak detection
24-hour signal continuity
24-hour professionally monitored video surveillance
Gas leak detection
Other
Alarm
What other alarm components does your system have?
Risk Mitigation Features
Please select the risk mitigation features of this property.
Stand-by back-up generator
Indoor sprinkler system
Automatic water shut-off valve
Lightning protection system
Gated house
Gated community
Perimeter fencing
Permanently installed safe
Flood vents
Seismic shut-off valve
LEED Certified
None
Other
Risk Mitigation Other
Enter the other risk mitigation feature(s) in this home.
Approximate Square Footage
What is the approximate square footage of this home?
Year Built
What year was this home built? (YYYY)
How many stories does this home have?
How many stories does this home have?
What is the age of your roof? (YYYY)
What is the age of your roof? (YYYY)
Please select your roof type:
Please select your roof type:
Asphalt Shingle
Architectural Shingle
Wood Shingle
Metal Roof
Flat Roof
Rubber Roof
Cement Tile
Clay Tile
Other
Please provide a description of your roof type:
Please provide a description of your roof type:
Construction Type
Please select the construction type of the home.
Wood frame
Brick
Masonry
Joisted Masonry
Stucco
Steel
Not Sure
Other
What is the construction type of your home?
What is the construction type of your home?
System/features Updates
Select the features of your home that have been updated within the last 10 years.
Electrical
Plumbing
Heating
Roof
Windows
None
Other
System/features updates other
What other updates have you done to your home?
What year did you update the electrical?
What year did you update the electrical?
What year did you update the plumbing?
What year did you update the plumbing?
What year did you update the heating?
What year did you update the heating?
What year did you update the roof?
What year did you update the roof?
What year did you update the windows?
What year did you update the windows?
What type of foundation does your home have?
What type of foundation does your home have?
Finished basement
Unfinished basement
Slab
Stilts
What percentage of your basement is finished? (ex. 100%)
What percentage of your basement is finished? (ex. 100%)
Property Structures
Please select the other structures on this property.
Pool
Pool house
Fence
Detached garage
Guest house
Jungle gym
Dock
Stone walls
Barn
Shed
Tennis court
Other
Other Property Structures
Enter a brief description of the other structure(s) on this property.
Pool fenced?
Is the pool completely fenced in?
Yes
No
Pool diving board or slide?
Is there a diving board or slide attached to the pool?
Yes
No
Attached garage?
Is there an attached garage?
Yes
No
Attached garage car bays?
How many car bays does the attached garage have?
Additional Risks
Please select the items below that are present or will be present at this home. (Select all that apply)
Trampoline
Dog
Wood burning stove
None
Trampoline net?
Is there safety netting around the trampoline?
Yes
No
Dog breed?
What breed of dog do you have?
Type of wood burning stove?
Please select the type of wood burning stove you have:
Insert
Free standing
Pellet stove
Other
Type of wood burning stove?
What type of wood burning stove do you have?
Valuable articles
Please select the types of valuable property you own.
Jewelry
Fine art
Other
None
Please tell us about your jewelry.
Please tell us about your jewelry.
Total collection value ($)
Number of items
Value of most significant item ($)
Please tell us about your fine art.
Please tell us about your fine art.
Total collection value ($)
Number of items
Value of most significant item ($)
Please tell us about your other valuable items.
Please tell us about your other valuable items.
Description
Total collection value ($)
Value of most significant item ($)
Would you like a flood insurance proposal for your home?
Would you like a flood insurance proposal for your home?
Yes
No
Documents and Comments
Please use this field to upload any relevant documents. (ie. Current policy declarations pages, jewelry appraisals, etc...)
Please use this field to upload any relevant insurance documents. (ie. Current policy declarations pages, jewelry appraisals, etc...)
Drop files here or
Please enter any additional remarks in the space below.
Please enter any additional remarks in the space below.
How did you hear about us?
How did you hear about us?
Current customer
Referred by...
Google search
Agency's website
Email newsletter
Facebook
Instagram
Twitter
Other
Please share who referred you to us.
Please share who referred you to us.
Can you share what you typed into Google?
Can you share what you typed into Google?
Please let us know how you heard about us.
Please let us know how you heard about us.
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Hitchings Insurance Agency
419-423-9145
http://hitchingsinsurance.com
info@hitchingsinsurance.com
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