Quotes - Homeowner's Insurance Form
Please fill in the form below as completely as possible and click Submit. We will get back to you as soon as possible.
Application Date:
Settlement Date:

Name:
Home Address:
Work Phone:
Home Phone:
Fax Number:

Property Address:
Mortgagee:
Mortgagee Phone:
Mortgage Amount:
Primary Residence:  yes    no
Secondary Residence:  yes    no
Rented to Others:  yes    no
Seasonal:  yes    no
Weeks Rented:
Square Footage:
Appraised Value:
Sale Price:
Personal Property:
Dwelling Limit:
RCV Contents:  yes    no
Limit of Liability:  $300,000    $500,000    $1,000,000
Construction:  Frame     Masonry     Fire Resistive     Other
Year Built:
Type of Heat:
Underground Tank:  yes    no
Improved Wiring:  yes     no    Year:  
Improved Plumbing:  yes     no    Year:  
Improved Heat:  yes     no    Year:  
Improved Roof:  yes     no    Year:  
Smoke Detector:  yes    no
Central Alarm:  yes    no
Local Alarm:  yes    no
Sprinkler:  yes    no
Miles to Fire Station:
Feet from Hydrant:
Swimming Pool:  yes    no
Above Ground Pool:  yes    no
Fence Around Pool:  yes    no
Garage:  yes    no
Attached Garage:  yes    no
Vents in Garage:  yes    no
Pets:  yes    no
Biting History:  yes    no
Primary Insurance Co:
Claims Last 4 Years:
Title Company:
Surveyor:
Untitled Page
Barra Vaughn Insurance | 226 West Avenue | Ocean City, NJ | 08226 | (609) 391-1856