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Home Owners Insurance Quote Form
  1. Home Owners Insurance Quote Form

  2. Name
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  3. Email(*)
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  4. Address(*)
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  5. City, State, Zip Code(*)
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  6. Mailing Address (if different)
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  7. Time at address:
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  8. Applicant's SS #
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  9. Co-applicant?
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  10. Co-applicant's name
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  11. Co-applicant's SS #
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  12. Phone #
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  13. Is there a mortgage?
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  14. Is home under construction?
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  15. Is there a business on premises?
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  16. Is there a pool?
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  17. If so, is it fenced?
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  18. Are there dogs?
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  19. Type of dog(s)
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  20. Have they bitten to the point of breaking the skin?
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  21. Are there horses or livestock?
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  22. Current carrier
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  23. Has insurance been cancelled in the past 5 years?
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  24. If so, why?
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  25. # of losses in the past 5 years and description
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  26. Number of mortgages
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  27. Equity line of credit?
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  28. Co-signer on mortgage
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  29. # of interests not indicated above
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  30. Other SAFECO products
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  31. Applicant's date of birth
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  32. Co-applicant's date of birth
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  33. Applicant's Employer
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  34. Co-applicant's Employer
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  35. Applicant's occupation
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  36. Co-applicant's occupation
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  37. Dwelling Info
  38. Is this a secondary dwelling?
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  39. Dwelling located in:
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  40. Year built
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  41. Type of floor covering:
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  42. Type of walls:
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  43. Type of cabinets in kitchen
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  44. Type of bath fixtures
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  45. Construction type
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  46. Roof type










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  47. Roof renovation
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  48. Year renovated
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  49. Wiring renovation
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  50. Year renovated
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  51. Plumbing renovation
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  52. Year renovated
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  53. Heating renovation
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  54. Year renovated
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  55. Heating system







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  56. Number of stories
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  57. Total living area (square feet)
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  58. Dwelling type
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  59. Condition
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  60. Hillslide slope
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  61. Dwelling built on
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  62. Garage size
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  63. Garage type
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  64. Fireplace
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  65. Number of full baths
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  66. Number of half baths
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  67. Square feet on these:
  68. Balcony/deck
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  69. Open porch area
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  70. Enclosed porch area
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  71. Open breezeway
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  72. Enclosed breezeway
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  73. Finished basement
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  74. Walk-out basement
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  75. Finished attic
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  76. Screened patio
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  77. Screened patio building
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  78. Coverages
  79. List the current coverage that you now have on your policy or that you want us to quote and the estimated present cash value
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