Serving the Adirondack Region
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Homeowners Quote Form
How did you hear about us ? _________________________________________________________________
First Name ____________________ M.________ Last Name_______________________________________
DOB:____________________________________ SS#:____________________________________________
Home Phone#_____________________ Work Phone#_________________ Email _____________________
First Name_____________________ M_________Last Name_______________________________________
Home Phone#_____________________ Work Phone#_________________ Email _____________________
DOB:____________________________________ SS#:____________________________________________
Credit Check Approval? ( Circle one ) Yes No
Address: Address: (If different from Property)
Street_______________________________ Street______________________________________
City________________________________ City________________________________________
State________________________________ State_______________________________________
Zip Code____________________________ Zip Code___________________________________
Home is? ( Circle one ) Primary Secondary Seasonal Winterized?________________________________
Have you moved in the past 60 days? ( Circle one ) Yes NO
Prior Address:______________________________________________________________________________
Current Ins. Co./Policy # _______________________________________________How Many Years?____
Any Losses in the last 3 Years? ( Circle one ) Yes No
Description of loss__________________________________________________________________________
Current policy form (HO2 or HO3)________________Current Coverage on Home $$ Amount______________
Liability (exp. $300,000)_________________________
Deductible (exp. $500)___________________________
Medical Payment (exp. $2,000)____________________
Is there a Mortgagee? ( circle one ) Yes No If YES , Name, address, phone#_______________________________
__________________________________________________________________________________________
Will policy be escrowed bill? ( Circle one ) Yes No
Smokers in household? ( Circle one ) Yes No
Any Pets? ( Circle one ) Yes No If YES - what kind/type______________________________
Distance from Fire Station?______________
Distance from Fire Hydrant?_____________
Is there a Swimming Pool? ( Circle one ) Yes No If YES , is it above ground or in-ground?
Is there a lockable gate/fence? ( Circle one ) Yes No
Is there a Trampoline? ( Circle one ) Yes No
Interested in other types of insurance coverage? Automobile – Recreational Vehicles – Umbrella – Watercraft – Life????
Print out Pages and Fax to 518-585-6446
Home Estimator Worksheet
| 1. House is 1, 2, 3, or 4 Family?: 1 2 3 4
2. Year Built________ 3. Number of Stories_____
4. Total Living Area, including additions: ________ Square Feet
5. Style of House: ( Circle only one ) -Ranch/Rambler -Bungalow -Bi-Level/Raised Ranch -Duplex -Colonial -Tri-Level/Split Level -Victorian -Cape Cod - Townhouse Center Unit -Contemporary -Mediterranean -Townhouse End Unit -Other___________________________________________.
6. Foundation Type: ( Must add up to 100% ) % Basement______ % Crawl Space________ % Slab_____ If you have a basement: Square Feet _______________ - Is it a walkout? Yes No - What percent of the basement is finished?________% - If basement is finished, the style of the finish is?
7. Exterior Walls? What percent of the outside walls are covered by the following materials? ( Must add up to 100% ) _____% Aluminum Siding _____% Brick _____% Vinyl Siding _____% Brick Veneer _____% Wood Siding _____% Stone _____% Clapboard Siding _____% Stone Veneer _____% Wood Shakes _____% Stucco on Frame _____% Concrete Block _____% Hardiplank 8. Roof Type: What percent of the roof is made up of the following materials? ( Must add up to 100% ) Age _____________ _____% Asphalt/Fiberglass Shingle _____% Slate _____% Architectural Shingle _____% Tin _____% Wood Shakes _____% Rubber _____% Wood Shingles _____% Clay Tile _____% Built up/Tar & Gravel _____% Concrete Tile
9. Heating and Air Conditioning: ( Please circle one ) - Heat Only - Central Air - Heat & Central Air Heat Type:___________________ and Age__________ If Oil Heat where is the Oil tank located:__________________
10. Electric Service: Size_________ and Age________________
11. Plumbing Type: ___________________ and Age_________ 12. Major Renovations_________________________________
13. Is your attic finished? ( Circle one ) Yes No
14. Give the size in Square Feet for any of the following structures attached to your home:
Decks: _____ Wood _____Redwood ____Composite Porches: _____ Open ____ Screened ____ Enclosed Breezeways: ______Open _____Screened ___Enclosed |
15. Indicate how many of each item in your home:
____Fireplace, Wood Burning ____Skylights ____Fireplace, Gas ____Hot Tub ____Bay Window ____Bow Window ____French Doors ____Picture Window ____Sliding Glass Door ____Woodstove
Other ( please describe ):______________________________
16. Interior Walls: What percent of the inside walls are covered by the following materials? ( Must add up to 100% )
____% Paint ____% Ceramic Tile ____% Vinyl Wallpaper ____% Built-in Bookcases ____% Paneling
Other (please describe):________________________________
17. Floors: What percent of the floors are covered by the following Materials? ( Must add up to 100% )
____% Wall-to-wall Carpet ____% Hardwood ____% Linoleum or Vinyl ____% Plank ____% Carpet Over Hardwood ____% Parquet ____% Marble Tile ____% Ceramic Tile
Other ( Please describe ) _______________________________
18. Does your home have a garage? ( Circle one ) Yes No If Yes , how many cars does it fit?: 1 2 3 4
Type of Garage: ( Circle all that apply )
Attached Built-In Basement Carport
19. Kitchens: Number and Type # of Standard __________ # of Custom __________
20. Bathrooms: Number and Type Standard Custom # of Half Baths: _____ _____ # of ¾ Baths: _____ _____ # of Full Baths: _____ _____
21. For dwellings built prior to 1940 : In the event of a loss, would the materials you select for reconstruction be modern materials or exact replica materials?
____Modern Materials (Examples: Sheetrock/Drywall walls, 8 foot ceilings, Standard wood, Concrete Foundations)
____Exact Replica Materials (Examples: Plaster Walls, 10 foot ceilings, Rough Lumber, Stone foundation) |