Davidson Insurance Agency

 

Print the quote information sheet.

Mail, fax, call or e-mail the information to our office.

You will be contacted within 48 hours of submission. *

*48 hours only applys if it occurs during our regular office hours. All requests will be contacted.

 

 

Name

DOB

SS#

Date

 

 

 

 

 

 

Mailing Address

Phone

Gender

Martial Status

 

 

 

o Male

oS oM oDoW

 

 

 

o Female

 

 

Property Address

Usage

 

 

 

 

 

o Primary

o Secondary

 

 

 

o Rental

o Business

 

oClaims

Date

Amount Paid

 

 

 

 

 

 

 

Description:

o Single Wide

oDouble Wide

o Modular

 

Length:

 

 

 

 

Width:

 

 

 

 

Make:

 

Model:

 

 

Serial #:

 

 

Home Value

$

Deductible Amt.

 

 

 

 

o $250.00

 

Lien Holder Information

 

 

o $500.00

 

 

 

 

o $1,000

 

 

 

 

o $2,500

 

Total # of Occupants

 

 

o Other

 

 

 

 

 

 

UNDERWRITING QUESTIONS:

 

 

 

 

 

 

 

 

 

Is there wood burning on premise?

Yes

No

If yes, UL/ ICBO Approved?

 

Is the home vacant?

Yes

No

 

 

Is the home for sale?

Yes

No

 

 

Do you own any aggressive pets?

Yes

No

If yes, what breed?

 

Is the home on a basement?

Yes

No

 

 

Is the home on farm property?

Yes

No

If yes, how many acres?

 

Is there a pool on premise?

Yes

No

 

 

Is there a trampoline on premise?

Yes

No

 

 

Continuous insurance on premise?

Yes

No

If no, expiration date of last policy?

 

 

 

 

 

 

Additional Notes: