Code Amber Code Amber
Nowak Insurance Nowak Insurance
 

HomeHome  
Get A QuoteGet A Quote  
About Nowak Ins.About Nowak Ins.  
Contact UsContact Us  
Insurance 101Insurance 101  
CompaniesCompanies  
Useful LinksUseful Links  

Home Owners Insurance Quote

Are You Frustrated with Agents Misquoting Rates and then Raising the Rate at Time of Sale?
*Providing the required information below will result in more accurate initial quotes.
 

Personal Information

First Name:*  
Middle Initial:  
Last Name:*  
Street Address:*  
Floor/Suite Number:  
City:*  
State:*  
Zip Code:*  
Email Address:*  
Phone Number:*  
(Enter 10 digits only)
Fax Number:  
(Enter 10 digits only)

Please Answer the Questions Below

Primary residence currently valued at less than $100,000?*   Yes No
 
Has there been more than one (1) property loss in the past three (3) years (including catastrophic losses)?*   Yes No
 
Any fire losses in the past three (3) years?*   Yes No
 
Any vandalism losses in the past three (3) years?*   Yes No
 
Any liability losses in the past three (3) years?*   Yes No
 
Any theft/burglary losses in the past three (3) years?*   Yes No
 
Any water damage losses in the past three (3) years?*   Yes No
 
Home occupied by more than two (2) families?*   Yes No
 
Roof been updated within the past 20 years?*  
 
If the house is valued at more than $750,000, is there a central alarm system?*  
 
If value of jewelry is higher than $100,000, does the house have a central alarm system?*  
 
If there is a woodstove, was it installed by professionals and according to code?*  
 
If there is a woodstove, is it the primary source of heat for the home?*  
 
If there is a woodstove, is home located within 5 miles of a fire station?*  
 
Any of the following terms describe the home: in course of construction, mobile home, open foundation, pier, stilts, pilings, vacant property, log home built prior to 1977 or non-split log construction?*   Yes No
 
Any vicious or aggressive pets, including, but not limited to Pit Bulls, Rottweilers, Presa Canario breeds, or any animals with a bite history?*   Yes No
 
Any underground fuel tanks or unfenced swimming pools?*   Yes No
 
Trampoline at this residence?*   Yes No
 
Ever convicted of vehicular homicide?*   Yes No
 
Multi-family dwelling with rental units?*   Yes No
 
Slope of the property more than 20 degrees?*   Yes No
 
Home constructed with asbestos building materials (including roof materials) or knob tube or aluminum wiring?*   Yes No
 
Home exposed to any known brush, range or forest fire, or within the susceptible path of an existing fire or location exposed to brush or forest fire?*   Yes No
 
Home exposed to any wave crash, cave in, sink hole or landslide loss exposure?*   Yes No
 
Square footage greater than 4,000?*   Yes No

Tell Us About You

Been at current address less than six (6) months?*   Yes No
Number of years at current address:*  
Social Security Number:
(Note: Required to provide an accurate price and to issue/bind a policy.)		  
Date of birth:*   Choose Date
Marital status:*  
Spouse's name:  
Spouse's Social Security Number:
(Note: Required to provide an accurate price and to issue/bind a policy.)		  
Spouse's Date of birth:   Choose Date
Occupation and type of business/industry:
(For example, sales person for a transportation company.)		  
Co-applicant relationship to insured:  
 

Prior Insurance Information

Have a current Homeowners Insurance Policy?*   Yes No
Insurance been cancelled or non-renewed within the past five (5) years?*   Yes No
Any Homeowners Insurance claims/incidents in the past five (5) years?*   Yes No

Residence1 Information

Street Address:*
(Note: P.O. Boxes are not allowed.)
City:*
State:*
Zip Code:*
County:*

For Pennsylvania, color photos of the front and back of home and all outbuildings, taken within past 6 months are required.

Description of residence:*
If the building is a Condominium or Apartment building, how many units does it have?
Style of owned residence:
Style of rental residence:
Number of stories:*
Type of construction:*
Dwelling type:*
Who occupies this residence?*
Year residence was built:*

If building is older than 20 years provide the following:

Year wiring was last updated:
Year plumbing was last updated:
Year heating was last updated:
Year roof was last updated:
Heating system type:*
Heating system type (if other):
Current replacement value:* $
Deductible:*
Name of the local/responding fire department:*
Distance (in feet) to nearest fire hydrant:*
Fire rating protection class code:*
Type of fire alarm:*
Type of burglar alarm:*
Sprinkler system?*
Deadbolt locks?* Yes No
Fire extinguisher?* Yes No
Total living area (square footage):*
What is the primary exterior wall constructed from?*
What is the secondary exterior wall constructed from?*
Type of roof:*
Type of foundation:*
Any specialty items and/or built-ins?* Yes No
If there are specialty item and/or built-ins, describe:
Percentage of the basement that is finished:* %
Walk-out/daylight basement?* Yes No
Square footage of finished attic:*
Describe the accessibility of the residence:*
Number of bedrooms:*
Number of full baths:*
Number of half baths:*
Number of single fireplaces:*
Number of double fireplaces:*
Number of gas fireplaces:*
Number of hot tubs or jacuzzis:*
Kitchen:*
Describe and provide the number of any special windows (e.g., atrium, bay, skylights, etc.):
Describe any other special features (e.g., wet bar, spiral staircase, etc.):
Type of garage:*
Construction of garage:*
Square footage of the attached porch:*
Type of attached porch:*
Square footage of the attached deck:*
Type of attached deck:*
Square footage of open breezeway:*
Square footage of enclosed breezeway:*
Any dogs on premises?* Yes No
Any horses and/or livestock kept on premises?* Yes No
Above-ground swimming pool?* Yes No
In-ground swimming pool?* Yes No
Air conditioning duct type:*
Value of all personal property (i.e., contents), excluding computers, software, and data:* $
Value of personal computer hardware, software and data?* $
Name, address, phone number of the mortgagee (i.e., mortgage company), if applicable:
If second mortgage, provide the name, address, phone number of the second mortgagee (i.e., mortgage company), if applicable.
Co-Signer on Mortgage?* Yes No
Equity line of credit?* Yes No
Loan number, if applicable:

Coverages

Personal Liability Limit:*  
Medical Payments to Others*  
Excess Liability coverage?*   Yes No
Mine Subsidence coverage?*   Yes No
Amount of Back-Up of Sewers and Drains coverage:*  
Amount of Mold coverage:*  
Building Ordinance Increased Cost coverage?*   Yes No
Assisted Living Care coverage?*   Yes No
Identity Fraud/Theft coverage?*   Yes No
Earthquake coverage?*   Yes No
Want home-based business coverage?*   Yes No
Home Child Day Care coverage?*   Yes No
Workers' Compensation coverage for domestic employees (e.g., live-in nanny, live-in housekeeper, etc.)?*   Yes No
Incidental Farming Liability coverage?*   Yes No

Scheduled Personal Property

Schedule any personal property?
(Note: All items valued in excess of $10,000 must be scheduled.)*		   Yes No
 

Contact us:

1913 S. Illinois St.
Belleville, IL 62220
Phone: 618-236-1500
  618-281-1700
Fax: 618-236-1501
Email: info@NowakInsurance.com
 
Home | Get A Quote | About Nowak Ins. | Contact Us | Insurance 101 | Companies | Useful Links


Copyright © 2006, Nowak Insurance Agency, All Rights Reserved