Welcome to the J.S. Braddock Agency

Homeowners Quote

*Fields marked in red are required*

Personal Information

First Name		Last Name
Street Address
City		State
Zip
Primary Phone
Secondary Phone

Social Security #
E-mail		How'd you hear about us?
		Other:
Do you currently have Homeowner's or Dwelling Insurance
	If yes, how long have you had continuous coverage?	Years	Months
	Present insurance company
	Policy Number:
	When does your policy expire?		ex: 09/30/2005
	Any losses in the past 3 years?	If yes, how many?
		Please give the Date Amount Paid Briefly Describe

If no, why?
	If other, why?

Home/Dwelling Information

Are you within 1000 feet of a fire hydrant?
Are you within 5 miles of a fire department?
Type of dwelling
Is this dwelling your primary residence?
	If no, will this residence be rented out?
	If no, will this residence be rented out for seasonal purposes?
What is the construction type?
Year of construction
Square Footage		If you do not know the exact number, please complete this form and contact our office.
Heating Type
	If oil, where is the tank located?
	Approximate age of tank
	If underground, is there a contracted oil tank service?
Wiring Type
	Date of most recent updates
Plumbing
	Date of most recent updates
Roof
	Date of most recent updates:
Do you have a burglar alarm?
Purchase Price
Is there a mortgage on the home
	If yes, what is the mortgage amount?

Coverage Information

Dwelling Limit		May be different from market value (i.e. the actual cost to replace the wood, nails, ceiling, etc.)
Liability Limit
Medical Payment

Other Information