| Name: |
|
| Email: |
|
| Phone: |
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| Property Address: |
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| City, State Zip: |
, SC
|
| Date of Birth: |
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| Marital Status: | |
| Spouse's Name/DOB: |
|
| Previous/Current Insurance Carrier: | |
| How long were you with your previous carrier? | |
| Have you filed any claims in the past five years? | |
| Current Premium: | |
| Current Policy Expiration Date: | |
| Discounts for which you may qualify: |
Claim Free
New Home
Home Buyer
55 & Retired
Protective Device
Renovated Home |
| Personal Property Coverage Amount: | |
| Personal Liability Coverage: | |
| Medical Payments: | |
| Deductible: | |
| Do you need increased coverage for items such as jewelry, furs, guns, etc.? | |
| If so, how much? | |
| Dwelling Coverage Amount: | |
| Home Information |
|
| Date of Purchase: |
|
| Year of construction: |
|
| Building style: | |
| Square footage: | |
| Approx. market value: | |
| Stories: | |
| Number of rooms: | |
| Bathrooms: | Full Half |
| Foundation type: | |
| Exterior Frame: | |
| Fireplaces: |
|
| What type? (Select all that apply) | |
| Do you have a monitired security system? | |
| Garage: |
Attached
Detached
|
 |
|
