6250 Old Dobbin Ln, Suite 100, Columbia, MD 21045
Phone: (443) 430-2390 | Toll Free: (877) 487-8341
Fax: (866) 922-3014 |
info@homeadvocate.net
Please provide as much information possible in the form below. This information will be kept confidential and will be used only for quote purposes.
General Information
Name:
Address:
City:
State:
Zip code:
County:
Email:
Office phone:
Home phone:
Best time to call:
am
pm
Occupation:
Soc. Sec. #:
How long at your current job?:
years
months
Current Homeowners Insurance Company (not agency)
Company name:
Policy expiration date:
/
/
Amount insured for:
$
Premium:
$
Term:
6 Months
1 Year
Other
Home Information
How long at present address:
years
months
# of claims in the past 3 years
Square footage of home:
(excluding garage and basement)
Year home was built
Structure Information
Type:
Construction:
Roof:
Foundation:
Garage:
1 Story
1 1/2 Story
2 Story
Split Level
Bi-Level
Other
Frame or Stucco
Masonry or Veneer
Masonry
Other
Asphalt Shingle
Wood Shingle
Tile or Slate
Other
Basement
Crawl Space
Slab
Other
1 Car
2 Car
3 Car
4 Car
None
Age of roof:
yrs.
Attached
Detached
Basement
Built-in
Car Port
None
Features
Bathrooms:
Basement:
Deck/Porch/Patio:
Fireplaces:
# of Full:
# of Half:
None
Finished
Unfinished
Sq. Ft:
Deck Sq. Ft:
Porch Sq. Ft:
Screened Patio Sq. Ft:
# of Chimneys:
# of Hearths:
Additional Features
Heating System:
Central Air:
Central Vac:
Security Alarm:
Fire Alarm:
Smoke Detector:
None
Electric
Gas
Oil
Propane
Solar
Other
yes
no
yes
no
None
Monitored
Not Monitored
None
Monitored
Not Monitored
yes
no
Insurance Coverages
Dwelling Amount
$
Contents Amount
$
Liability Amount
$
List Scheduled Items
Jewelry
Silver
Furs
Antiques &
Collectibles
Other
Additional Information
Please give any additional comments about the coverage you desire:
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Phone: (443) 430-2390 | Toll Free: (877) 487-8341 | Fax: (866) 922-3014
