Section 1.1 - Home Information

Address*

Town*	State*	Zip*

Year Built (if unknown, enter best estimate)*	Total Square Footage*

Year Rennovated

Year of Last Known Updates
Heating	Roofing

Electrical	Plumbing


Structure Type*	# of stories (not including attic or basement)*

This is a*	Roof*

Size of Lot (Acres)*	Basement*


Is this home named in a trust?

Name of Trust

Is the house within 1000 feet of a fire hydrant?

Section 1.2 - Home Information Continued

Interior features (check all that apply)
Smoke Detectors	Local Burglar Alarm
Alarm Company Monitored: Fire Alarm Burglar Alarm Temperature

Exterior features (check all that apply)
Swimming Pool	Gas/Oil Tank
Trampoline	Skateboard Ramp
Treehouse

Do you have any of the following?
StabLok/Federal Pacific Electric Panel
Space Heaters
Wood, Pellet or Coal Stove
Please provide name of the installation company
Date of last inspection
Interior Oil Tank
Interior Oil Tank Age
Exterior Oil Tank
Exterior Oil Tank Age
Propane Tank
Propane Tank Location
Propane Tank Age
Fuses

Is there any known Lead Paint Hazard?

Do any household members smoke?
Do any adults in the household work less than 20 hours?
Do you have any pets?		Please list breeds*:
Is there a business on premises?		What type of business?*
Are there any residence Employees?

Is this property currently for sale?
Is this building currently Under Construction?
Is there any existing damage to this building?
Has the Heat, Water, or Public Lighting been out of service for the last 30 days or more?
How many weeks per year is the property rented (if applicable)?
Do you currently have insurance on the property?
Carrier	Dwelling Limit

Deductible	Wind Deductible

Premium	Expiration

Is this a new property purchase?
Closing date

First Name*	Last Name*

Enter Other Names to be listed on policy

Email Address*	Phone*

Mailing Address*
Home address is the same as mailing address

Town*	State*	Zip*

Date of Birth*	Social Security Number*	Occupation*


Have you had any coverage Declined, Canceled or non-Renewed during the last 3 years?
Have you had a Foreclosure, Repossession, Bankruptcy, Judgement or Lien during the last 5 Years?
Have you been convicted of any Arson related Crime in connection with this or any other property?
Are you indebted to an Insurance Agent, Broker, or Company?
Have you failed to pay Real Estate Taxes on the Property for One Year or More?

Please check all that apply and provide descriptions where indicated.
Boat
Boat Year
Boat Length
Make/Model
Horse Power (if applicable)

Jewelry

FineArt

Electronics

Firearms

Please Describe any other personal property that you think may affect your quote

Add

Please note appraisals will be needed before policy is finalized

Check any that you own
	Snow Mobile	Jet Ski
	ATV	Dune Buggy
	Mini-Bike	Dirt Bike
	Motorized/Electric Bicycle, Trike or Scooter


Rogers & Gray includes $1,000,000 of umbrella coverage in every homeowners quote.

Would the applicant like to request a higher limit on your umbrella quote?
Number of Vehicles*
Are there any drivers in the household with less than 6 years experience?*
Do you own any other properties not listed on this quote?
Please Describe
Do they have additional boats (over 26 ft) not listed on this quote?*

Have there been any property losses within the past five years?
Please describe

Please select Payment Method*
Employer Name*
How did you hear about us
Service Office Preference*

Please enter the number shown in the graphic for verification purposes*
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