Home Insurance Quote Form

Page Insurance, Ltd

102 Boston Street

Guilford, CT 06437

(203) 453-5258

info@pageins.com
Effective / Closing Date*

MonthDayYear
Is this a new purchase?*

YesNo
Current Insurance Company:*
Current Annual Insurance Premium:*
Where did you hear about Page Insurance?
Name*

First NameLast Name
DOB*

MonthDayYear
Occupation*
Marital Status*
Other Named Insured?*

YesNo
Spouse / Other Named Insured*

First NameLast Name
Spouse / Other DOB*

MonthDayYear
Occupation*
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
E-mail*
Phone Number*
What is the best day/time to get in touch with you?*

MorningAfternoonEveningAnytime
Best Method to Contact*

PhoneEmailEither
Location Address is the same as the mailing address
Location Address

Street Address

Street Address Line 2

CityState

Zip Code
Do you have city water?*

YesNo
Is the house within 1,000 feet of a fire hydrant?*

YesNo
Protection Class (if known)
FOR UNDERWRITING USE
Build Quality*

AverageSemi-CustomCustom

Quote Requirements

	Yes	No
Replacement Cost Calculated?
Assessors Field Card
Canceled/Non-Renewed/Declined Past (3) years?
Claims in the past (3) years?
Continuous Coverage for Past Year

If Yes, Explain:
CURRENT / PROPOSED POLICY LIMITS
Dwelling Limit*
Other Structures
Personal Property
Loss of Use
Liability Limit
Medical Payments
Number of Families*

12345More than 5
Usage Type*

PrimarySecondarySeasonalOther
Occupany*

Owner OccupiedTenant OccupiedOwner Occupied with Some Rental
If tenant occupied or rental, how many weeks is it rented per year.
If Tenant Occupied, do you have an annual lease?

YesNoN/A
Is there any of the following short term/property sharing rental exposure:

AirBnBVRBOHipCampNone
Do you rent to college students or anyone under the age of 21?

YesNo
Do you / tenants have any dogs?*

YesNoOther
Other Animals / Pets*

YesNoOther
Do you have a wood stove?*

YesNo

Swimming Pool*

YesNo
Above or In-ground?

Above GroundIn Ground

Fence/DB/Slide?

	Yes	No
Fenced
Diving Board
Slide

Do you have any of the following?

	Yes	No
Do you have a trampoline?
If yes, does it have a net around it?
Do you have an underground Oil tank?
Do you rent to college students?
Do you conduct any business In the home?

Type of In-Home Business
Average # of Clients Daily

Do you have an alarm system?

	Yes	No
CS Burglar
CS Fire
Local Smoke
Deadbolts
Fire Extinguishers

BUILDING AND UPDATE INFORMATION
Year Built
Square Feet
Construction Quality

Builders GradeSemi-CustomCustom
Type of Basement
Is the basement finished?

YesNoN/A
What percentage of the basement is finished?*
Roof Updates*

YesNoOriginalUnknown
Year*
PartialComplete
Plan to replace roof?*

YesNo
If yes, when?*
Electrical Updates*

YesNoOriginalUnknown
Year*
PartialComplete
# Amps*

60100200

Circuit Protection*

	Yes	No
Circuit Breakers
Any fuses?
Knob/Tube Wiring

Plumbing Updates*

YesNoOriginalUnknown
Year*
Heating Updates*

YesNoOriginalUnknown
Year*
Type of Heat*

OilGasElectricPropane
Type of updates*
Location of Oil Tank:*
Last Service Date

MonthDayYear
Do you have a mortgage?*

YesNo
Mortgagee Information
Contact Information @ Bank
If New Purchase, do they require payment in full for the first year?

YesNo
Who will be billed on renewal?

BankInsured
Other Location #1
Other Location #2
Other Location #3
NOTES
CLIENT INFORMATION Entered in IntellectQUOTE Task Created in IntellectCreate Folder in Scanned docs
Once policy has been sold obtain following Documentation:

Signed Application, quote, payment etc.Signed Cancellation if applicableSigned Flood Selection / Rejection letter or Quote requestSigned Personal Umbrella Quote Selection / Rejection Form
Amend task to Priority "Inbox" assign to ASTRID
Set up policy in Prime
Create contact in PrimeCreate policy (including the A-Trans)Attach the following document in order: (Most documents can be found in insured folder Scanned docs)--- Information sheet--- property card--- replacement cost calculation--- application(s)--- quote(s)--- Signed application--- Bind request if applicableCopy notes all from intellect to Prime.Delete folder from scanned docs
Amend task to Priority "Inbox" assign to @ Daily
ADD TO ENEWS Task create in Intellect (Priority B, Assign @daily)SEND THANK YOU NOTE task create in intellect (Priority B, Assign @daily)
Amend task to Priority "NEW BUSINESS" assign to Pending new business
Should be Empty:

	Yes	No
Prof Install
Inspected?
Cleaned Annually

FOR UNDERWRITING USE