Your Contact Info

First Name Last Name

Email

Your Phone Number?

Best Time to Call? AM PM any time

Property Info

Policy owner's full name? (if different from above)

Address? (Please include street, city, state and zip code)

Property address? (street, city, state and zip)

Is/will this property be your primary residence? Yes No

Do you own or rent? Own Rent

If new purchase, please list purchase date and price.

Had property/liability claims within the last 5 years?
Provide each date, description and claim amount ($).

Had a policy cancelled by an insurer within the last 5 years?
Yes No
Insurer?

Cancel Date?

Reason?

Number of units in the building (defined by number of apartments including the owner's)?

Year the building originally constructed?

Number of rooms in your unit?

Swimming pool? Yes No

Diving board? Yes No

Is the pool fenced in? Yes No

Any pellet/wood stoves? Yes No

Any trampolines? Yes No

Any pets? Yes No

What kind(s) of animals? Please specify the breed for any dogs.

Any asbestos in the house?
Yes No

Building construction? Wood Frame Masonry

Does the building have a fire protection sprinkler system?
Yes No

Does your unit have a centrally monitored burglar system?
Yes No

Optional Coverage

Valuables coverages (jewelry, antiques, works of art) ? Please give appraised values.

If you are requesting a quote for a condo, please provide the amount of building coverage desired for building items not covered under Master Condo Policy (e.g. interior walls, floors, light fixtures, etc.)

Earthquake coverage? Yes No

Extra computer equipment coverage for equipment used in a business? Please describe the equipment you wish to cover.

Home based business coverage? Please describe the type of business, inventory levels and annual sales.

Would you like a quote on personal umbrella for extra liability coverage? Yes No

Any other requirements or underwriting issues?

How did you hear about Beacon Insurance?

Web search Print Ad Local Yellow Pages

If a friend, what's their name?

If an agent, please list the agent's name here