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Homeowners Insurance Quote

Name:

Home Phone

Your Email:

Cell Phone

Date Homeowners coverage needed:

Name on Deed

Applicant 1 (Deed):

Applicant 2 (Deed):

Location being Insured

Address (Insured Property):

State (Insured Property):

Social Security Number Applicant 1 (Insured Property):

City (Insured Property):

Zip Code (Insured Property):

Social Security Number Applicant 2 (Insured Property):

Mailing Address if different

Address (For Mailing):

State (For Mailing):

City (For Mailing):

Zip (For Mailing):

Years at Address (Insured):

Prior address of less than 3 years

Prior Address if less than 3 years:

Prior State if less than 3 years:

Prior City if less than 3 years:

Prior Zipcode if less than 3 yrs:

DOB for applicants (Important)

Applicant 1 DOB:

Applicant 2 DOB:

About Your Home

Year home was built:

Do you rent this property out?

Yes

No

# of Miles from Fire Station:

Stories:

How many bedrooms:

Garage?

Yes

No

Is this a secondary home?

Yes

No

Within 1000 feet of fire hydrant?

Yes

No

Type of Home (ie Colonial):

Square footage of Dwelling:

How many bathrooms:

Attached garage?

Yes

No

How many cars?

Basement?

Yes

No

Full Basement?

Yes

No

% of Basement finished?

Large deck or screened porch?

Yes

No

Size of deck or porch

Heating type?

Is there a wood or coal burning stove

Yes

No

Type and age of roof:

Are rooms average or custom grade?

Is there an oil tank?

Yes

No

Age of oil tank:

When was last update on wiring:

Do you have circuit breakers?

Yes

No

When was last update on heating system?

When was last update on plumbing?

Sump Pumps

Do you have a sump pump?

Yes

No

Do you have a battery back up system?

Yes

No

How many sump pumps?

Are you interested in sump pump overflow coverage?

Yes

No

Siding

What kind of siding?

Percentage siding on home?

Pool

Do you own a pool?

Yes

No

Do you have a slide?

Yes

No

Is pool fenced in?

Yes

No

Do you have a diving board?

Yes

No

Trampoline or Tree House

Do you have a Trampoline or Tree House?

Yes

No

Pets

Do you have pets?

Yes

No

Type/Breed:

Bite history?

Yes

No

Business

Do you conduct business on the premises?

Yes

No

Type of Business?

Occupation of all applicants

Applicant 1 Occupation:

Applicant 2 Occupation:

Insurance Carrier

Current Carrier

Policy #:

Current Premium:

Current dwelling amt on policy:

Current liability coverages:

Is policy in force?

Yes

No

If so, how long?

Has your policy lapsed?

Yes

No

Reason for lapse:

Any scheduled items (ie jewelry):

ANY homeowners claims in the past 5 years? If so, please provide dates, details and amounts paid out.

Purchase price (if new):

Mortgage Clause:

Mortgage Amount

Is your homeowners escrowed?

Yes

No

What other type(s) of insurance are you looking for today?

Personal Property:

Renters

Condo

Flood

Umbrella

Vehicle:

Automobile

Motorcycle

RV or Motorhome

Classic Car

Business:

Business Owner's Policy

General Liability

Business Auto

Commercial Property

Workers' Comp

Commercial Umbrella

Bonds

Comment or Message:

Coverage will not be bound or changed until confirmed by a licensed agent.

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Franchino Agency

856 US Highway 206, Suite B11
Hillsborough, NJ 08844
Phone: (908) 359-2044
Email: info@franchinoagencyinc.com

Mailing address:
Franchino Agency
P.O. Box 6403
Hillsborough, NJ 08844

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