Homeowner/Contact Information |
* Todays Date: (mm/dd/yyyy) |
* Owner's First Name: |
* Owner's Last Name: |
* Street Address: |
* City: |
* State: |
AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY |
* Zip: |
* County: |
* Valid Email Address:
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* Home Phone: (999-999-9999) |
* Work Phone: (999-999-9999) |
* Owner's Date of Birth: (mm/dd/yyyy) |
* Owner's Gender: |
Male Female |
Owner's Social Security Number: (e.g. 555-55-5555l) |
* How would you (owner) describe your credit rating?: |
Poor Good Excellent Unsure |
* Current Residence Status: |
Own Rent Live With Parents Dormitory Choice Not Listed |
* Length of time at current residence?: |
* Best time to contact you?:
* Best way to contact you?:
|
Anytime Morning Afternoon Evening
Email Phone Work Phone
|
* How quickly do you need your request processed?: |
ASAP 1 Day 2 Days 3 Days 4 Days 5 Days 6 Days 1 Week |
Please provide any comments you have: |
Are you interested in a multiple-policy discount (for auto and home insurance)?: |
Yes No |
* Are you currently (or have you ever been) a Brooke customer? |
Yes No |
* How did you hear about Brooke? |
Insurance Information |
Please tell us more about your current or recent insurance policy. Be as accurate as possible. |
* Your most current insurance company: |
* What date does your current policy expire/renew? (mm/dd/yyyy) |
* How long have you been insured with your current insurance company?: |
* How long have you been continuously insured with this company? |
Property Location and Type |
* Address of the property to be quoted: |
Address 2 or Apt. Number: |
* City/Township: |
* County/Parish: |
* State: |
AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY |
* Zip Code: |
* Please select the property type: |
Single Family Home Multi Family Home Apartment Duplex Condominium Townhome Mobile Home Other |
* Do you currently own (or are you in the process of purchasing) this property?: |
Yes No |
* Do you now reside, or plan on residing at this property within the next 12 months?: |
Yes No |
Property Coverage Information |
* How much Residence coverage do you want?: (In dollars, for example: 250,000) |
* How much personal liability coverage do you want?: |
100,000 300,000 500,000 1,000,000 |
* How much deductible?: (The higher your deductible, the lower your premiums) |
100 250 500 1000 2000 |
* Approximate year property built: |
* Approximate livable square footage of residence: (excluding basement, if any) |
* Is this your primary or secondary residence?: |
Primary Secondary |
* Is business or farming conducted on this property?: |
Yes No |
* Do you have any of the following breeds of dogs: Chow, Doberman, German Shepherd, Pit Bull, Rottweiler, Wolf Hybrid, or mix of these?: |
Yes No |
* Dwelling design: |
One Story Bi Level Two Story Tri Level Other |
* Exterior wall type: (60% or more) |
Aluminum or Vinyl Siding Mostly Brick Mostly Wood Frame Stucco Cinder Block Mostly Stone Veneer Log Other |
* Number of Bedrooms: |
1 2 3 4 5 6 7+ |
* Number of Bathrooms : |
1 1.5 2 2.5 3 3.5 4+ |
* Roof Type: |
Composition Shingle Tile Wood Shingle Concrete Other |
* Roof Age: |
1-5 years 6-10 years 11+ years |
* Garage Type: |
Attached - 1 Car Attached - 2 Car Attached - 3 Car Attached - Carport Detached - 1 Car Detached - 2 Car Detached - 3 Car Detached - Carport No Garage Other |
* Describe Foundation or Basement: |
Bsmt Fully Finished Bsmt 3/4 Finished Bsmt 1/2 Finished Bsmt 1/4 Finished Bsmt Unfinished Crawl Space Piers Pilings Stilts Slab Other |
* Wiring Type: |
Copper Aluminum Knob and Tube Unknown |
* Service Panel Type: |
Circuit Breaker Fuse Box Unknown Other |
* Central Burglar Alarm: |
None Monitored Unmonitored |
* Central Fire Alarm: |
None Monitored Unmonitored |
* Fire Station: |
Within 5 Miles Within 10 Miles Over 10 Miles |
* Fire Hydrant: |
Within 1000 Feet Over 1000 Feet |
* Municipal Location: |
Inside City Limits Outside City Limits |
* Please describe the heating system in this dwelling: |
Gas (Forced Air) Electric Boiler Oil/Coal/Kerosene Propane Stove Unknown Other |
* Number of gas, pellet or wood fireplaces or stoves: |
0 1 2 3 4 5 |
* Is your home prone to flooding or located in a designated flood plain?: |
Not Applicable Designated Flood Plain Prone to Flooding |
* Property Accessories |
Dead Bolts |
Air Conditioning |
Tennis Court |
Smoke Detectors |
Covered Deck/Patio |
Trampoline |
Fire Extinguisher |
Uncovered Deck/Patio |
|
Indoor Fire Sprinkler |
Swimming Pool |
|
|
Claims Information |
Claim Type: |
Fire or Lightning Damage Windstorm or Hail Damage Ice Snow Sleet Damage Smoke Damage Water Damage Vandalism Theft Loss Claim Not Listed |
Date of Claim: (mm/dd/yyyy) |
Claim Type: |
Fire or Lightning Damage Windstorm or Hail Damage Ice Snow Sleet Damage Smoke Damage Water Damage Vandalism Theft Loss Claim Not Listed |
Date of Claim: (mm/dd/yyyy) |
Claim Type: |
Fire or Lightning Damage Windstorm or Hail Damage Ice Snow Sleet Damage Smoke Damage Water Damage Vandalism Theft Loss Claim Not Listed |
Date of Claim: (mm/dd/yyyy) |
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