| First Name: Last Name: |
| Address: Apt./Unit: |
| City: State: Zip: |
| Home Phone: Work Phone: Cell: |
| Email: Fax Number: |
| Add me to your E-mail list |
| Applicant Information |
| Location of property if different from above: |
| |
| Applicant's Occupation |
| Employers Name |
| Employers Address |
| Marital Status Date of Birth Social Security # |
| Co-Applicant Information |
| Co-Applicants Name Social Security # |
| Occupation Marital Status D.O.B. |
| Coverages - Limits of Liability Please be sure you answer ALL questions in this section. |
| Dwelling Coverage $ Personal Liability- each occurance $ |
| Medical Payments- ea. occurrance $ Deductible- All Peril Only $ |
| Payment Plan |
| All Policies are Direct Bill please choose either 'Bill Applicant' or 'Bill Mortgagee' |
|
| Rating/Underwriting - choose "Yes", "No", or "N/A" |
| Year Built Square Footage of Living Area # of Rooms |
| Purchase Date Purchase Price $ Market Value |
| Frame Masonry Vinyl Siding |
| Visible to Neighbors Fire Extiguisher Protective Smoke Device |
| Dead Bolt # of Families # Household Residents |
| Structure Type Roof Type Heat Type Primary |
| Active Burglar Alarm Oil Storage Tank |
| Distance to Fire Hydrant Ft. Distance to Fire Station Miles |
|
| Swimming Pool If you DO have a swimming pool, please answer the following: |
| Approved Fence Diving Board Above Ground In-Ground |
|
| Renovation Type Part Full Year Completed |
| Wiring |
| Plumbing |
| Heating |
| Roofing |
| Exterior Paint |
| General Information - Please choose "Yes", "No", or "N/A" |
| Explain all "Yes" Responses in Remarks (below) |
| 1. Any other business conducted on premises? Including Day/Child care? |
| 2. Any other residence owned, occupied or rented? |
| 3. Any coverage declined, or non-renewal during the last 3 years? |
| 4. Does applicant or tenant have any animals or exotic pets? (Note breed and bite history) |
| 5. Is building undergoing renovation or reconstruction? (estimated completion date and $ value) |
| 6. Is house for sale? |
| 7. Is there a trampoline on the premises? |
| 8. Are there any smokers in the home? |
| Renters and Condos Only: |
| 1. Is there a manager on the premises? |
| 2. Is there a security attendant? |
| 3. Is the building entrance locked? |
Remarks:
|
| Loss History |
| Any losses, whether or not paid by insurance, during the last 3 years at this or any other location? |
| Date: Type: Amount Paid: |
| Description of loss: |
| |
| Additional Interest- Mortgagee |
| 1) Name & Address Loan Number |
| 2) Name & Address Loan Number |
| Inland Marine |
| Property Amount of Insurance Property Amount of Insurance |
| Jewelry $ Furs $ |
| Fine Arts $ Musical Instruments $ |
| Silverware $ Stamps $ |
| Guns $ |
|
| Policy Effective Date |
| Disclaimer: By completing and submitting this form, COVERAGE IS NOT BOUND.
Thank you for taking the time to complete this homeowners quotation application.
An SAS Insurance Representative will reply shortly.
|
|
For further information, please contact us: SAS Insurance233 Kearny Avenue
Kearny, New Jersey 07032
Phone: (201) 997-2360
michael@sasinsurance.com |
