HIGH VALUE HOME INSURANCE QUOTE REQUEST

Applicant’s Name(s):
Occupation(s):	Date(s) of Birth:
Risk Address (full):
Broker:	Years known to broker:
Number of financial interests in this address:

Policy Information:
Effective Date:	Policy #:
Name of Previous Carrier:	Previous Policy #:
Prior carrier renewal premium:
Years with continuous insurance:
Has any insurer cancelled, declined or refused to renew Habitational Insurance to the Applicant within the past 5 years? No Yes

Loss History
Have there been any losses or claims by the applicant in the past 5 years? If yes, complete below: No Yes
Date of Loss	Location #	Cause	Paid Amount	Insurance Company	Policy #
Risk Information:
Replacement cost of the risk:
Year built:	Number of years at this location:	Number of families:
Is the home vacant? No Yes
Is the home under construction? No Yes, details
Business activity in the home? No Yes, details
Distance to Hydrant:
Distance to Firehall:	Name of responding Firehall:
Alarm information:
Fire alarm: No Yes	Burglary: No Yes
Coverages:
Deductible requested: $1,000 $2,500 $5,000 $10,000 $25,000
Liability Requested: $1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000
Items to be scheduled and their replacement costs: