A.H. Meyers Online HomeOwners Quote Form
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Please provide the following contact information:

Name
Address
City
State
Zip
Day Phone
Eve. Phone
FAX
E-mail
Send Quotes via	U.S.Mail E-Mail Fax

 

Choose The Reason You Require Homeowners Insurance:
New Purchase
Policy Canceled
Re-Finance
Policy Lapsed
Paying Too  Much
How many claims have you made in the last 5 years?(give claim details and dates in section)
Current Insurance Company (if none, please type none)
Policy Expiration Date

 

Type of Home
	One Family
	Two Family
	Three Family
	Four or More

Occupancy:(check all that apply)
Owner Occupied
Rented to Others
Second Home
Owner & Tenant

Specific Information on the Home

Construction of Home
Wood Frame/Vinyl or Aluminum siding Brick/Masonry Concrete
Style of Home
Select One Ranch Cape Split Level Colonial Raised Ranch Contemporary Row House (attached on either side) Town House
Number of Stories
Select -> 1 1.5 2 2.5 3 3.5 4 or more (excluding basement)
Approximate living area in square feet
(excluding basement)
What year was the home built?   Approximate if unsure.
(ex.1968)
What type of Foundation supports the home
Concrete Slab Crawl Space Basement(finished) Basement (unfinished) Pilings
Roofing Material
Asphalt or Architectural Shingles Clay or Spanish Tile Slate Wood Shake (very old homes)
	Roofing shingles last replaced (enter year, original, or unsure)
Type of Heating
	Select One Oil Gas Electric Steam
	Oil or Gas Burner replaced or updated (enter year, original, or unsure)
If oil heat, where is the tank?
	Buried in ground Above ground In crawl space or basement
Electrical System
	How many amps in electrical service (60,100,150,200)
	Does your electrical system have circuit breakers? Yes  No
	Electrical System Upgraded (enter year, original, or unsure)
Garage Type
	Select One None Attached Built-in(rooms above) Detached
# of cars garage holds
	None 1 1.5 2 2.5 3 3.5 4 or more
Security Features (check all that apply)
	Smoke Detectors Fire Extinguishers Dead Bolts Local Burglar Alarm(rings outside home) Local Fire Alarm (rings outside home) Central Station Burglar Alarm Central Station Fire Alarm (Central station means connected directly to a monitoring facility that contacts police or fire dept on your behalf)
Home Features
	Central Air	No Yes
	Number of Bathrooms	1 1.5 2 2.5 3 3.5 4 5 5.5 6
	# Fireplaces	None 1 2 3 4
	Wood Stove	Yes No
	Swimming Pool	None Above Ground In-Ground
	If yes, Diving Bd.	Yes No
	If yes, fenced in	Yes No

Insurance Coverages

Insurance Coverages
	What is the purchase price of the dwelling? $
	Mortgage Amount $
	Dwelling Amount
	Personal Property Cov.
	Personal Liability Cov	$100,000 $200,000 $300,000 $500,000 $1,000,000
	Building Deductible	$100 $200 $250 $500 $1000 $2500
	Is Flood Coverage Required?	Yes No
	If  Flood is requested, how much coverage is needed?
	Flood deductible
	Do you need coverage for scheduled personal property (jewels, furs, silver) beyond what the standard policy offers? Usually big ticket items.	Yes  No If yes, give amt in $'s for each example $12,000 Jewelry $ Furs     $ Silver    $ Other
Underwriting Questions
Underwriting questions (as you may know, credit has become a major factor in obtaining insurance in a number of states, so please be aware that where applicable, rates will be quoted based on your responses below)
	Filed For Bankruptcy in last 5 years?	Yes No
	Do you have a dog? If so, what breed(s)	Yes No
	Other types of insurance we have:	Auto   Business Auto  Flood   Boat/Yacht Umbrella

Comments/Questions