"Home / Dwelling Fire Quote Form - Randig Insurance Agency"

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Referred by _________________________ Producer _________________________ Date________________
Name__________________________________________________________ Phone _______________________________________
2nd Name Insured________________________________________________ Email _______________________________________
DOB____________ Social Security_______________ Occupation________________________________ Education Level _______
DOB____________ Social Security_______________ Occupation________________________________ Education Level _______
Current Address__________________________________________________ City________________ State______ Zip __________
Property Address_________________________________________________ City________________ State______ Zip __________
Current Insurance Carrier_______________________________________________________________ Expires _________________
Dwelling Amount_________________________________ Deductible__________________________________________________
Any Prior Losses? q Yes q No_______________ If yes, please explain. _______________________________________________
New Home Purchase q Yes q No If yes, please give close date _______________________________________________________
Information on Quote Property
q Single Family q Duplex q Other________________________ Occupancy____ Construction_____________________________
Year Built____ Sq Ft____ Stories____ Roof Type___________ Roof Year____ Foundation________________________________
Check all that apply:
q Swimming Pool q Fenced q Diving Board q Slide
q Monitored Alarm q Dogs, Breed____________ q Trampoline q In Home Business, Type _____________________________
Distance to fire Department_______________________ Distance to fire hydrant ___________________________________________
Number of Bathrooms____ Number of Fireplaces____ Central Heating: q Yes q No Flooring____________________________
Garage: q Attached q Detached Number of Cars__________
Update Info: Check all that apply and brief description:
q Heat__________________ q Wiring___________________ q Plumbing____________________ q Roof
Name_________________________________________
Name_______________________________________
Address_______________________________________
Address_____________________________________
Loan Number__________________________________
Loan Number_________________________________
Escrow Bill_________________________________________ Mortgage Contact Name____________________________________
Phone Number______________________________________ Email___________________________________________________
Notes:
WIG-001
H
/ D
F
Q
F
ome
welling
ire
uote
orm
GROUP
GROUP
Referred by _________________________ Producer _________________________ Date________________
Name__________________________________________________________ Phone _______________________________________
2nd Name Insured________________________________________________ Email _______________________________________
DOB____________ Social Security_______________ Occupation________________________________ Education Level _______
DOB____________ Social Security_______________ Occupation________________________________ Education Level _______
Current Address__________________________________________________ City________________ State______ Zip __________
Property Address_________________________________________________ City________________ State______ Zip __________
Current Insurance Carrier_______________________________________________________________ Expires _________________
Dwelling Amount_________________________________ Deductible__________________________________________________
Any Prior Losses? q Yes q No_______________ If yes, please explain. _______________________________________________
New Home Purchase q Yes q No If yes, please give close date _______________________________________________________
Information on Quote Property
q Single Family q Duplex q Other________________________ Occupancy____ Construction_____________________________
Year Built____ Sq Ft____ Stories____ Roof Type___________ Roof Year____ Foundation________________________________
Check all that apply:
q Swimming Pool q Fenced q Diving Board q Slide
q Monitored Alarm q Dogs, Breed____________ q Trampoline q In Home Business, Type _____________________________
Distance to fire Department_______________________ Distance to fire hydrant ___________________________________________
Number of Bathrooms____ Number of Fireplaces____ Central Heating: q Yes q No Flooring____________________________
Garage: q Attached q Detached Number of Cars__________
Update Info: Check all that apply and brief description:
q Heat__________________ q Wiring___________________ q Plumbing____________________ q Roof
Name_________________________________________
Name_______________________________________
Address_______________________________________
Address_____________________________________
Loan Number__________________________________
Loan Number_________________________________
Escrow Bill_________________________________________ Mortgage Contact Name____________________________________
Phone Number______________________________________ Email___________________________________________________
Notes:
WIG-001