Checks & Balance - Financial Services

HOMEOWNERS QUOTE

THE DECISIVE DIFFERENCE INC. (315)433-1180

Name
Address
Address2
City
State, Zip
Telephone

Location of Risk:

Address
Address2
City
State, Zip
County

	Any other residence occupied or rented?
	Yes No

	Number of Families:

Construction:

Frame

Masonry

Other

Year Built or Age:
Type of Heat & Age of System:
Age of Electrical System:
Age of Roof:
Number of Our Buildings:
Market Value:
Date Purchased:
Woodburning Stove:	(if yes please fill out questionnaire)
Any Business Conducted on Premises:	(including day/child care, etc.)
Animals on Premises:	(if yes please fill out questionnaire)
Previous/Current Carrier:
Previous/Current Carrier Premium:
Has Coverage Been Canceled, Declined or Non-Renewed Within The Past 3 Years:
(if yes please explain)
Losses/Claims Within Past 5 Years:	Yes No
(if yes please explain)

Credits:

Smoke Detectors:

Yes No

Fire Alarm :

Yes No

(if yes include brand name & model)

Security System :

Yes No

Distance to Fire Hydrant:

Distance to Fire Station:

Coverage:

ITEM:

COVERAGE AMOUNT:

Residence

Related Private Structures

Unscheduled Personal Property

Additional Living Expense/Loss of Rents

Personal Liability

Medical Payments to Others

Deductible:
Mortgage:
Problems with Personal Credit:	Yes No

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