Homeowners Insurance Quote Checklist

Homeowners Insurance Quote Checklist

Linsey Mills | Insurance Broker | 336.287.5643 ph
*Please provide as much information as possible so we can apply all the discounts available for you*
Full Name Deeded Owner*

First NameMiddle NameLast NameSuffix
Gender
Birth Date*
Social Security Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Previous Address (if at current location under 3 years)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mailing Address (if different from Home Address)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell Number*

Area CodePhone Number
Other Number

Area CodePhone Number
E-mail
Highest Level of Education
Employer's or School's Name and Address
Occupation
Current Homeowner's Insurance Carrier
Current Premium (Please Indicate Monthly/ Semi-Annual or Annual)
Policy Expiration Date*
How Long with this Carrier
Continually Insured Since Date
Upload 1st Page of Homeowner's Policy

Browse Files
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Spouse / Domestic Partner
Spouse/Partner Name

PrefixFirst NameMiddle NameLast NameSuffix
Gender
Social Security Number
Birth Date
Cell Number

Area CodePhone Number
Occupation
Employer's or School's Name and Address
Home Occupancy
Is Home a New Purchase?
Purchase Price
Closing Date
Current Dwelling Limit
Liability Limit
Deductible
Year Built
Square Footage of Home
Detached Structures (Sheds, Utility Buildings, etc)
Square Footage of Detached Structures
Construction
Exterior Cover
Garage
Garage Square Footage
Number of Stories
Style of Home
Number of Families Living in Home
Number of Full Bath Rooms
Number of Half Bath Rooms
Fireplace / WoodStove / Alternative Heating
Is Home On Over 5 Acres of Land?
Basement/Crawl-space
Do You Have A Sump Pump
Porch
Porch Square Footage
Deck Square Footage
Pool (Select All That Apply)
Pets / Breed and Mix Breed
Does Home Have The Following? (Select All That Apply)
Home Visible From Main Road
Home Visible To At Least 3 Neighbors
Do You Own A Trampoline / Bike or Skateboard Ramp
Does Anyone in the Home Smoke
Responding Fire Department
Miles To Fire Department
Fire Hydrant Within 1000 Feet of Home
Type of Roof / Age of Roof
Plumbing
Year of Last Plumbing Update
Heating Type
Age of Heating System
Date of Last Heating Service
Is Your Furnace Serviced Annually
Oil Tank
Is Your Electric on Circuit Breakers
Mortgage Company Name and Address and Loan Number
Any Business Conducted on Property or Rented to Others? Please provide details.
Do You Have Live-In Residence Employees? Please provide details.
Will Your Insurance Premium Be Paid From Escrow?
Do You Belong to A Homeowner's Association?
Are Any Structures On Your Property Rented To Others?
Do You Have Valuables That Need To Be Scheduled. Please provide details.
Do You Have Claims Within The Last 5 Years?
Is Your Current Insurance Being Cancelled?
Additional Comments / Information
Additional Documents
Front of Home Picture #1

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Right Side of Home Picture #2

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Left Side of Home Picture #3

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Back of Home Picture #4

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Document Upload #5

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Document Upload #6

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Document Upload #7

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Document Upload #8

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Document Upload #9

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Document Upload #10

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By submitting your information, you agree to the following terms:

Insurance Coverage cannot be bound or changed via submission of this online form/application, e-mail, voice mail or facsimile. No binder, insurance policy, change, addition, and/or deletion to insurance coverage goes into effect unless and until confirmed directly with a licensed agent and or your insurance company.

Thank you for the information. We will review and contact you with a consultation and quote.

Linsey Mills

336.287-5643 ph

LMills@ebgnc.com
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