Your Name Address City County Allegheny Armstrong Beaver Butler Crawford Erie Fayette Mercer Lawrence Washington Westmoreland State Pennsylvania Zip Code Telephone Number Fax Number E-Mail Address
Type of Coverage: Homeowners Renters/Tenant
Home Description
Construction Brick Frame (including Frame with Siding) Year Built If home is over 20 years old, please advise the date the following items have been updated: Plumbing Heating Electrical Roof Number of Families/Apartments in Building Is your home or apartment within 5 miles from a Fire Station? Yes No Is your home or apartment within 1,000 feet from a Fire Hydrant? Yes No
Coverage Limits Current limit of coverage or replacement cost of home
For Renters Only Personal Property/Contents Coverage limit desired Deductible $100 $250 $500
Scheduled Items/Valuable Items: List any items which you desire to have scheduled for an agreed amount , i.e. Jewelry, Furs, Silverware:
General Information: Have you had any homeowner claims or losses within the last 3 years? If so, please explain: Do you have a swimming pool? Yes No If so, is the pool completely fenced in? Yes No
Additional Residences: Please list any additional residences that you may own.
Location
No. of Families
Occupancy
Dwelling Use
Currently Insured
One Two Three Four
Owner Tenant Vacant Unoccupied
Primary Seasonal Secondary
Yes No
Any Protective Devices Installed in Your Home? Smoke Alarms Dead Bolts Fire Extinguishers Local Fire System Local Fire & Burglary System Central Fire System Central Burglary & Fire System
Do you currently have Homeowners Coverage? Yes No If so, who is your present insurance carrier? Expiration Date:
