Salvione Insurance - Easy Home Quote

1. Tell Us About Yourself

Name:	Home Phone:
Address:	Business Phone:
City:	Best Time to Call :
State:	Work	Home
County:
Zip:



Employer:	*Soc. Sec. No.:
Home Insurance Exp. Date:	*License Number:
Current Company (not agent):	Date of Birth
Current Coverages:
Dwelling:
Contents:
Liabilities:
Deductible:


*Call us or fax any information with security issues!

2. Tell Us Abut Your Home
For the most accurate quotation, refer to your existing policy and check coverages that apply.


I own a home and it is:	1 family 2 family 3 family 4 family
Style of home:	1 story 2 stories 2+ stories
Number of square feet in living area:
I live in a mobile/modular home	I own a condo
I rent a condo/apartment	I rent home/condo to others
Construction is:	Frame Frame/Brick Solid Masonry
	Other
Year built:
Smoke detectors:	No Yes
Other alarms:	No Yes
Describe:
Office studio or other business in your home?	No Yes
Describe:
Electrical system protected by circuit breakers:		No Yes
Have roof, plumbing, heating and electrical systems been updated in the last 20 years?		No Yes
If Yes, when?
Do you need special coverage for jewelry, furs, camaras, guns etc?		No Yes
If Yes, specify.
Have you had any losses to your proprety in the past three years?		No Yes
If Yes, when?
Do you use a wood stove or a pellet stove?		No Yes
Describe:

If renting:
Number of units in your building:
Value of personal property in condo/apartment:
Expiration of current insurance:	Month
	Year
Current company:
Deductible:	$

Street City, State, Zip Code

Inside city limits Outside city limits
If outside then name of responding fire department

Are you within 1,000 feet of a fire hydrant? Yes No

Distance to fire department: Miles	Hydrant Feet