Homeowners Insurance Proposal Request
Georgia and Alabama Residents ONLY

Your Full Name:
Address:
City:
State:
Zip Code:
County:
Home Phone:
Work Phone:
Fax:
E-Mail Address:
Date of Birth:
Social Security Number:

The some of the following questions may require information contained on your current homeowners policy. If you do not have your current policy available for review leave the "answer" provided. You may leave comments or questions at the end of the questionaire.

Residence Information
HO Form Select Home Owner Tenant/Renter Condominium Owner
Inside City Limits? Yes No
Is This a Primary or Secondary Residence? Select Primary Secondary Year Built
Construction Type Select Frame Stucco Brick
Deductible Amount Select 100 250 500 1000 2500
Replacement Value of Residence:
Square footage:

Coverage Information
Personal Liability Select 100,000 200,000 300,000 400,000 500,000 1,000,000
Medical Payments Select 1000 2000 3000 4000 5000 10000

Replacement Cost Options
Replacement Cost on Dwelling
Replacement Cost on Contents

Protective Devices
Smoke Detectors
Dead Bolt Locks
Fire Extinguisher
Non Smoker
Central Station Burglar Alarm (rings at a monitoring center)
Central Station Fire Alarm (rings at a monitoring station)
Police Station Direct Alarm (rings at police station)
Fire Station Direct Alarm (rings at fire station)
Local Burlar Alarm (rings on the premises only)
Local Fire Alarm (rings on the premises only)
Automatic Sprinkler - All Areas
Automatic Sprinkler - Excluding Attic, Bath, Closet

Additional Coverages
Scheduled Property - Enter Total Dollar Amount of Itemized Coverage for each Category

Silverware:
Camera:
Musical Instr.:
Personal Furs:
Personal Jewelry:
Jewelry in Vaults:
Guns:
Golf Equipment:

Earthquake Coverage? (Not Covered unless you select coverage) Select No Yes

Flood Coverage? (Not Covered unless you select coverage) Select No Yes


Please list all claims and amounts paid for the last 3 years:

Use this area for any special comments or coverages which need special attention.



Do you currently have homeowners insurance? Yes No
Who is you current homeowners insurance company?
When does your current policy expire?