HOMEOWNER'S INSURANCE QUOTE REQUEST *If you do not know the answer, please leave it blank* Name #1-- First: Initial: Last : Date of Birth (month/day/year) : Social Security # Name #2-- First: Initial: Last : Date of Birth (month/day/year) : Social Security # Contact Phone: Cell: Email: Address: City: State: Zip: Property's 911 address: County: Town: Purchase price: Year purchased: Do you reside at the property? Yes, we live here No, we do not live here Select How many years? If less than 5 years, please provide previous address: Is the property used for an office or business? Yes No Select Distance (miles or yards) to Fire Department: ... to fire hydrant: May we do a credit check? Select Yes No We will not see your confidential information. We cannot price your insurance without your written permission to do a credit check. Current insurance with: # Years: What is the amount of your current coverage for: Dwelling: Appurtentant Structures: Personal Property: Loss of Use: Deductible: Liability Limit: Medical Payments: Premium: Any losses in the past 5 years? Amount paid: Explain: Number of dogs: Are they aggressive? Yes No Select Breed: Do you have a trampoline? Yes No Select Description of the house: Year built: Number of families: Construction: Select Masonry Frame Other Stories Please Select 1 story 1 and 1/2 story 2 stories Acreage: Garage: Select Attached Detached Do you have a pool? Select In ground Above ground No Pool Does the pool have: a diving board? a slide? pool area is fenced? Basement : Select Full Partial Crawlspace Finished or Unfinished: Select Finished basement Unfinished basement Chimney: Select Shared Separate Smoke Detectors on each floor? Select Yes No Deadbolts on all outside doors? Select Yes No Security System? Yes No Select --- Living Area (Square Feet) --- House: Porches: Decks: Garages: Any additional porches or decks? If yes, give square footage: --- Number of Rooms --- Kitchens: Living Rooms: Bathrooms: Bedrooms: Other: --- Flooring--- % Carpet: % Vinyl: % Laminate: % Hardwood: Other: --- Exterior Walls--- % Vinyl % Wood: Other: --- Interior Walls --- % Plaster: % Sheetrock: % Paneling: Other: --- Alternative Heating --- Monitor - Wood Stove - Fireplace - Fireplace with fan Solar - Baseboard Electric -- Other? --- RENOVATIONS DONE ON PROPERTY--- Plumbing — Year: Completely Renovated? Partial Renovation? Describe: Roof — Year: Completely Renovated? Partial Renovation? Describe: Heating — Year: Completely Renovated? Partial Renovation? Describe: Wiring — Year: Completely Renovated? Partial Renovation? Describe: Type of Electrical System: Select Circuit Breakers Fuses Amperage: For your security, please type the five-letter code you see below. Use USE ALL CAPS. Then click the SUBMIT button to send your information to Lynette P.Thompson. How did you hear about us? Type the code here: Your final premium is subject to verification of information. Coverage can only be bound by authorized representative of L.P. Thompson Insurance, LLC. All information provided will be held in strictest confidence and used only for the purpose of providing an accurate rate for this specific policy. Your information will not be shared with anyone for any purpose other than the stated purpose of this form.
HOMEOWNER'S INSURANCE QUOTE REQUEST *If you do not know the answer, please leave it blank*
Name #1-- First: Initial: Last : Date of Birth (month/day/year) : Social Security #
Name #2-- First: Initial: Last :
Date of Birth (month/day/year) : Social Security #
Contact Phone: Cell: Email:
Address: City: State: Zip:
Property's 911 address: County:
Town: Purchase price: Year purchased:
Do you reside at the property? Yes, we live here No, we do not live here Select How many years?
If less than 5 years, please provide previous address:
Is the property used for an office or business? Yes No Select
Distance (miles or yards) to Fire Department: ... to fire hydrant:
We will not see your confidential information. We cannot price your insurance without your written permission to do a credit check.
Current insurance with: # Years: What is the amount of your current coverage for: Dwelling: Appurtentant Structures: Personal Property: Loss of Use: Deductible: Liability Limit:
Medical Payments: Premium:
Any losses in the past 5 years? Amount paid:
Explain:
Number of dogs: Are they aggressive? Yes No Select
Breed:
Do you have a trampoline? Yes No Select
Description of the house:
Year built: Number of families: Construction: Select Masonry Frame Other
Stories Please Select 1 story 1 and 1/2 story 2 stories Acreage: Garage: Select Attached Detached
Do you have a pool? Select In ground Above ground No Pool
Does the pool have: a diving board? a slide? pool area is fenced?
Basement : Select Full Partial Crawlspace Finished or Unfinished: Select Finished basement Unfinished basement
Chimney: Select Shared Separate Smoke Detectors on each floor? Select Yes No
Deadbolts on all outside doors? Select Yes No Security System? Yes No Select
--- Living Area (Square Feet) ---
House: Porches: Decks: Garages:
Any additional porches or decks? If yes, give square footage:
--- Number of Rooms ---
Kitchens: Living Rooms: Bathrooms: Bedrooms: Other:
--- Flooring---
% Carpet: % Vinyl: % Laminate: % Hardwood: Other:
--- Exterior Walls---
% Vinyl % Wood: Other:
--- Interior Walls ---
% Plaster: % Sheetrock: % Paneling: Other:
--- Alternative Heating ---
Monitor - Wood Stove - Fireplace - Fireplace with fan
Solar - Baseboard Electric -- Other?
--- RENOVATIONS DONE ON PROPERTY---
Plumbing — Year:
Completely Renovated? Partial Renovation?
Describe:
Roof — Year:
Heating — Year:
Wiring — Year:
Type of Electrical System: Select Circuit Breakers Fuses Amperage:
For your security, please type the five-letter code you see below. Use USE ALL CAPS. Then click the SUBMIT button to send your information to Lynette P.Thompson.
How did you hear about us?
Type the code here:
Your final premium is subject to verification of information. Coverage can only be bound by authorized representative of L.P. Thompson Insurance, LLC. All information provided will be held in strictest confidence and used only for the purpose of providing an accurate rate for this specific policy. Your information will not be shared with anyone for any purpose other than the stated purpose of this form.
