Personal Property Quote Request Personal DataInsured Name:*Current Address:* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Number of Years at This Address:*Married?YesNoHome Phone:Format: (XXX)XXX-XXXXWork/Cell Phone:*Format: (XXX)XXX-XXXXFax:Email Address:*Quote Flood Insurance?*YesNoProperty Address:* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is this a commercial account?*YesNoWhich of the following applies to you currently:*OwnerTenantEffective Date:*Title Company:*Title Company Phone Number:*Format: (XXX)XXX-XXXXAre you a first-time home buyer?*YesNoPrior Insurance Company:*Policy Number:*Effective Date:*How long were you insured by this company?*Smoker?*YesNoDo you have a dog?*YesNoPredominant Breed (No "multi" or "mixed breed"):Auto Carrier:*Expiration date:*Any other animals or exotic pets?*If yes, please describe:Any property claims in the past 5 years?*If yes, please explain:Has your coverage ever been cancelled or nonrenewed?*If yes, please explain:Prior Address (if less than 3 years): Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insured Name:*Date of Birth:*Social Security Number:*Occupation:*Employer:*Years with employer:*Insured's highest level of education:*Spouse Name:*Date of Birth:*Social Security Number:*Occupation:*Employer:*Years with employer:*Policy CoveragesMarket Value:*Loan Amount:*Replacement Value:*Dwelling Limit:*Contents Limit:*Liability Limit:*Loss Assessment Limit:*Deductible:*Hurricane Deductible:*Extended Dwelling Replacement Cost?*YesNoContents Replacement Cost?*YesNoFirst Mortgagee:* Loan Number:*Escrow?*Increase Special Limits?*Do you want Personal Umbrella Coverage?*Any items to be scheduled? (Jewelry, furs, fine arts, etc.)*Any business conducted on premises?*Any additional residences for liability?*Trampoline?*YesNoWatercrafts?*YesNoRecreational Vehicles?*YesNoMobile Home?*YesNoFarming?*YesNoExcess Flood?*YesNoLiability Extended?*YesNoDwelling InformationType?* Single Family Home Duplex Tri-Plex Four-Plex Townhouse Condo If condo, number of stories in building:Number of units in building:What floor is condo on?Year built:*How many stories:*Square feet:*Type:* Masonry Masonry Veneer Frame Aluminum/Vinyl Siding Modular Fire Resistive Foundation:* Slab Raised If raised, how high?*Is it enclosed?*If enclosed, what type of material?*Alarm System? (Fire Alarm, Burglar Alarm..)*YesNoIf so, is it local or monitored?*Do you have a:Fire AlarmBurglar AlarmBothSmoke detectors, fire extinguishers, deadbolts, etc?*Electrical - Year Updated:*Electrical Wiring* Copper Aluminum Romex Knob & Tube Electrical - Circuit Breaker or Fuses?*Plumbing - Year Updated:*Plumbing* Galvanized PVC Copper Heating - Year updated:*Floor furnance, wall or space heaters?*Central Air & Heat?*Wood burning stove?*Number of Bathrooms:*Bathrooms:* Basic Custom Designer Number of Bedrooms:*Number of Fireplaces:*If any fireplaces - wood burning, brick chimney, metal chimney, gas?% of Floor (Wood, carpet, ceramic, vinyl or other)*% Wall Covering (Paint, wallpaper, paneling..)*Ceiling Height:*Cathedral Ceiling?*Ceiling Fans? How many?*Wet Bar, Jacuzzi, etc..?*Number of French/Sliding Doors?*Bars on windows?*Atrium, Bay or Picture windows?*Are windows hurricane resistant?*Storm Shutters? Type:*Garage or Carport? - # of Cars*If garage or carport, is it attached or detached?Basement?*YesNoSquare Feet?*Finished or Unfinished?*Attic?*YesNoSquare Feet?*Finished or Unfinished?*Pool?*YesNoDiving Board?*YesNoSlide?*YesNoAbove Ground?*Fence with self-locking gate?*Porch/Deck/Patio... ?*If so, square feet?If so, is it opened/screened/enclosed?Roof - Age of roof:*Roof - Gable, Hip or Flat?*Roof material - Asphalt, Slate, other?*Roof - # of roof overlays:Once you have completed this quote form, we will evaluate the information provided and get back with you shortly to continue the process. Completing the form does not guarantee a quotation from our agency or any of the companies or brokers we represent. Thank you for allowing us an opportunity to discuss your insurance needs. Learn more about the value of working with The O'Connor Agency, an INDEPENDENT TRUSTED CHOICE AGENCY.