|
Date Coverage Needed:
|
|
Property Address To Be Insured |
|
Street Address:
|
|
City:
State: Zip:
County:
|
|
|
|
Current Address |
|
Street Address:
|
|
City:
State:
Zip:
|
|
|
|
Current Homeowners
Insurance With:
For Last: |
|
|
|
Number of homeowner's insurance claims filed in
last 5 years:
|
|
|
|
Number of Dogs in Household:
Breeds (select any that apply):
|
|
|
|
Primary Insured:
Date of birth: |
|
|
|
Work Phone:
X
Home Phone:
|
|
Email:
|
|
|
|
Second Insured:
Date of birth: |
|
Work Phone:
X
Home Phone:
|
|
Email:
|
|
|
|
IMPORTANT: In order to provide an accurate quote,
our agents may order one or more consumer reports. A consumer
report may contain information on credit history, driving records
and prior claim history. Entering your Social Security Number(s)
below, acknowledges that you understand
this information may be obtained, possibly from a third party,
and used solely to generate your quote. Jones Logan's Privacy
Policy explains how we disclose and protect your information. Primary Insured's Social Security#
Second Insured's Social Security#
|
|
|
|
Coverage
Information
|
|
Purchase Price |
|
Personal Liability Limit |
|
|
AND/OR |
|
Medical Payments Limit |
|
|
Recent Appraisal |
|
Deductible |
|
|
|
|
|
|
|
|
|
Property Information |
|
Year Built: Construction:
Roof Type:
|
|
|
| |
|
Owner Occupied?
Occupancy:
|
|
|
|
Applicable Discounts |
|
Dead Bolts: Fire Extinguishers:
Smoke Alarms
|
|
Burglar Alarm:
Fire Alarm:
Non-Smoking Household
|
|
|
|
Referred by:
from: |
