HOMEOWNERS INSURANCE QUOTATION FORM

To help us supply you with the most accurate quote possible, please answer as many questions as you can with the most accurate information available to you. We need Name, Date of Birth, SS#, Occupation and Employer for each named insured.

Information submitted will be held confidential and will be used for quote purposes only. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

PERSONAL INFORMATION

First Name:
Last Name:
E-mail address:
Daytime Phone Number:
Evening Phone Number:
Fax Number:
How would you prefer to be contacted regarding your quote?	Phone Fax Mail E-mail
If you would prefer to be contacted by phone, please let us know the best time to call.	AM PM
Address:
City:
State:
Zip code:
Social security number:
Occupation:
Date of birth:
Employer:

STRUCTURAL INFORMATION

What is the style of your home?
How many stories is your home?
How many rooms do you have?
What is the total square footage of the living area of your home?

WHAT IS THE STRUCTURE OF THE FOLLOWING

Roof:
Exterior of your home:
Foundation:
Most of the inside walls consist of:
Most flooring consists of:
Garage:
What is the replacement cost of your home:

HOW MANY OF THE FOLLOWING DO YOU HAVE IN YOUR HOME

Full bathrooms:
Half bathrooms:
Fireplaces:
Decks:
Enclosed porches:
Open porches:

DO YOU HAVE THE FOLLOWING IN YOUR HOME

Swimming pool?	Yes No In-ground Above-ground Fenced Not fenced Slide Diving board
Trampoline?	Yes No
Kerosene, gas or oil stove?	Yes No
Wood burning stove? If yes, was it professionally installed and inspected?	Yes No Yes No
Is there an oil tank?	Yes No Above ground In basement Underground N/A
Dog?	Yes No If yes, what breed? Bite history? Yes No
Computer?	Yes No
Livestock?	Yes No If yes, how many?
Unusual/exotic pets?	Yes No

IS YOUR HOME LOCATED

Within 1000 feet from a fire hydrant?	Yes No
Within 5 miles from the firestation?	Yes No
On a hillside?	Yes No
Close to a body of water or susceptible to flooding?	Yes No

GENERAL QUESTIONS

Year home built:
If house is over 20 years old, have there have been any updates to the Roof, Electrical, Heating and/or Plumbing?
How many acres do you own?
On a hillside?	Yes No
Number of families living in the home:
What part of the year is the home occupied?
Heating system:
Cooling system:
Electrical system:	Circuit breakers Fuses
What term best describes your kitchen?
Is business conducted on the premises?	Yes No
Does anyone in your home smoke?	Yes No
Did you experience any loss or claims in the last 5 years?	Yes No If yes, please give details:

PROTECTIVE DEVICES

Burglar alarm?
Sprinkler system?
Smoke detectors?	Yes No
Fire extinguishers?	Yes No
Fire alarm?
Deadbolt locks?	Yes No

ADDITIONAL INFORMATION

Do you own any other properties?	Yes No
Have you had any bankruptcies or foreclosures?	Yes No
Prior Insurance Company and Expiration Date?
Mortgage Company name and address:

HOMEOWNERS COVERAGES AND DEDUCTIBLES

Dwelling (Coverage A - Replacement cost of your home):	$
Other structure (Coverage B - Typically 10% of coverage A):	$
Personal property/contents (Coverage C - Typically 70% of coverage A):	$
Loss of use of your home (Coverage D - Typically 20% of coverage A):	$
Personal liability:	$
Medical payments:	$
Desired deductible:	$

ADDITIONAL DATA

Quote requested within:	24 hrs 48 hrs 72 hrs 120 hrs
Do you want an umbrella quote:

OPTIONAL QUESTIONS

If you have a collection that is anything of value such as Coins, Stamps, Art etc., specify the value of your collection:

If you have any furs or jewelry, please specify the approximate value/limits:

Do you have any special interests or hobbies that could be considered a home based business?

Yes No

Do you travel?

Yes No

Do you travel outside of the United States?

Yes No

When you travel, do you bring valuables such as watches, jewelry, or furs with you?

Yes No

Do you buy things while traveling and want to know that they are immediately insured under your policy?

Yes No

If your home were destroyed, would you want to rebuild it in the same location?

Yes No

Do you have/want backup of sewers and drain coverage?

Yes No

REMARKS

Quotation Forms


Auto	Home	Life	Business

J.A. Archambault & Son, Inc.

Main Office
Archambault Insurance Associates
143 Providence St., P.O. Box 153, Putnam, CT 06260-0153
Phone: (860) 928-0811 Fax: (860) 928-6462
Toll Free: (877) 928-0811
www.archambaultins.com
E-mail: marc@archambaultins.com

Archambault Insurance Associates
136 Main Street/Suite 104, Danielson, CT 06239
Phone: (860) 779-5030 Fax: (860) 774-2025
Toll Free: (866) 779-5030
E-mail: tom@archambaultins.com