Dwelling/Homeowners Quote

Agency Information

Agency Name *

Agency Code *

Phone *

Agent First Name *

**Please use the name of the agent that is submitting this quote**

Agent Last Name *

Email *

Insured & Property Information

Is this in a Company/Trust/Inc/Corp? *

Yes

Company/Trust/Inc/Corp Name *

Insured - First Name & Last Name *

Phone Number Type *

Work

Home

Mobile

Other

Phone Number *

Client's Date of Birth *

MM/DD/YYYY

SSN

Email Address

Add Additional Insured? *

Yes

Relationship to Applicant? *

Additional Insured - First Name *

Additional Insured - Last Name *

Additional Insured - Phone Number *

Phone Number Type *

Work

Home

Mobile

Specify

Additional Insured - Date Of Birth *

MM/DD/YYYY

Additional Insured - SSN

Additional Insured - Email Address

Requested Effective Date: *

State the dwelling is located in *

Physical Address of Property *

Country

City

State

Zip code

Mailing Address: *

Country

City

State

Zip code

Mailing address same? *

Yes

Dwelling Settlement Option: *

Actual Cash Value

Replacement Cost

Full Repair Cost

Reason for vacancy: *

Non-Residential - Such as: Boat Dock, Pole Barn, Picnic Shelter or Casita *

Underwriting:

Year Built *

Construction Type: *

Number of Stories: *

Square Footage of Building: *

Do not include the basement (finished or unfinished) in Finished Living Area.

Protection Class:

Type of roof: *

Roof Style: *

Hip

Gable End with Bracing

Gable End without Bracing

Flat

**PROOF IS REQUIRED FOR THE ROOF STYLE THAT HAS BEEN SELECTED**

Year roof was replaced: *

Architectural Elements *

No Pool Enclosures

Pool Enclosures (Fence, Screen)

Unknown

Opening Protection *

No Protection

Glazed openings designed for pressure and missiles (no doors)

All openings designed for pressure and missiles

Unknown

Secondary Water Resistance *

Yes

Unknown

Is the primary heat source thermostat controlled? *

Yes

Heating Type: *

Gas

Electric

Other - Specify:

Is any supply or exit line plumbing made of galvanized, Polybutylene, cast iron, or lead? *

Yes

Estimated Valuation *

Discounts & Surcharges - Documentation for some discounts may be required and can be uploaded below

Will the applicant enroll in paperless policy delivery? *

Yes

Applicant's email address: *

Will this be mortgagee billed? *

Yes

Will the applicant be paying in full? *

Yes

Does the applicant have more than 1 AMIG policy with Graham-Rogers? *

Yes

Please advise the policy number: *

Does the applicant have their auto policy written with your agency? *

Yes

Has there been any claims for ALL properties owned in the last 5 years? *

Yes

Has the applicant had similar insurance declined, cancelled, or non-renewed? *

Yes

Reason for prior decline, cancellation, or non-renewal: *

Describe Other *

Number of dwellings owned? *

Is the applicant a member of AAA, USAA or Landlord Association? *

Yes

If Yes, please attach documentation below.

Loss Type *

Date of Loss *

Amount of Loss *

Explain cause, details and damages of loss *

Is the claim open or closed *

Open

Closed

Add another claim? *

Yes

Loss Type? *

Date of Loss? *

Amount of Loss? *

Explain cause, details and damages of loss? *

Is the claim open or closed? *

Open

Closed

Add another claim: *

Yes

Loss Type: *

Date of Loss: *

Amount of Loss: *

Explain cause, details and damages of loss: *

Is the claim open or closed: *

Open

Closed

Add another claim. *

Yes

Additional claim information: *

Is there currently any damage to the dwelling? *

Yes

Please advise current damage to the dwelling in detail: *

Is dwelling designated as historical? *

Yes with tours

Yes with no tours

Please provide a description of dwelling history and description of updates. *

Any Farming or Business operations on premises? *

Yes

Explain what Farming or Business operations on premises: *

Any Animals or Pools? *

Yes

Please select which:

Animals

Pools

Explain type of animals: *

Number of animals: *

Type of pool: *

Fencing or security measures for pool: *

Lockable Gate? *

Yes

Pool slide above 5ft? *

Yes

Diving Board? *

Yes

Will the dwelling be occasionally rented to others less than 3 months? *

Yes

Has the dwelling gone uninsured? *

Yes

Number of days uninsured? *

Please explain why the dwelling has gone uninsured: *

Is the building under construction/renovation? *

Yes

Who will be completing the renovations? *

Provide a detailed list of ALL interior and exterior renovation/construction work planned *

Supplemental Heating Source (including wood/pellet burning stove)? *

Yes

Please advise what the source is: *

Wood Stove, Pellet Stove, Wood burning Fireplace, Fireplace Insert, Gas Fireplace. Other

Any central or local alarms? *

Yes

If Yes, please attach documentation below.

Please advise alarm information: *

Is the alarm: *

Burglary Only

Fire Only

Both Burglary & Fire

Deadbolts, Fire Extinguishers & Smoke Alarms: *

Yes

Property Purchase Date: *

Purchase Price: *

Is this a new purchase? *

Yes

Current Carrier: *

Expiration Date: *

Coverages:

Dwelling Limit: *

Is other structure coverage wanted? *

Yes

Detached Structures Coverage Amount: *

Is personal property coverage wanted? *

Yes

Personal Property: *

Personal Property Settlement Option: *

Actual Cash Value

Replacement Cost

Deductible: *

$1,000

$2,500

$5,000

Additional Living Expenses: *

Is the applicant wanting Liability Coverage? *

Yes

Liability: *

Med Pay: *

Vacant Under Renovation Limit: *

Total value of dwelling after renovations: *

Please provide photos and any supporting documentation you have: *

Document 2

Document 3

Document 4

Any Additional Questions or Comments?

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