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Applicant Information
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| Name: |
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| Street Address: |
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| City/State/Zip: |
/ / |
| Home Phone: |
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| Work Phone: |
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| Email: |
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Coverage Selections
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Personal Property Limit: |
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Liability Coverage Limit: |
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| Medical Payments
to Others: |
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| Deductible: |
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| Off Premises Theft
Coverage: |
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| Replacement Cost
Contents: |
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| Replacement Cost
Dwelling: |
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Loss Assessment
Coverage
(for Condominium/Coop owners): |
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| Building Additions
and Alterations Coverage: |
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Property Information
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Property
Address: |
Street : |
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| City/State/Zip: |
/ / |
| Construction Type: |
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| Year Built: |
"yyyy" |
| Square Footage: |
sq. ft. |
| # Rooms: |
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| # Apartments: |
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| Market Value: |
$ |
| Replacement Cost: |
$ |
| Structure Type: |
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| # Families |
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| # Household Residents: |
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Live-Ins
(ex. housekeeper, babysitter): |
yes/no |
| Is any resident a smoker?: |
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| Purchase Date: |
"mm/dd/yyyy" |
| Purchase Price: |
$ |
| Distance to Hydrant: |
ft. |
| Distance to Fire Station: |
mi. |
Wired Alarm Systems
(connections to fire/police
authorities): |
Fire Alarm?: yes/no |
| Burglar Alarm?: yes/no |
| Fuel: |
Gas |
Oil
|
If "Oil" is checked,
"Storage Tank Location" below is required.
Storage Tank Location
(ex.
"basement"): |
| Electric |
| Wood |
| Coal |
| Solar |
| Please enter Year of
Renovation, if applicable, for the items at right. |
Electrical: |
yyyy
|
| Plumbing: |
yyyy |
| Heating: |
yyyy |
| Roof: |
yyyy |
| Exterior Painted: |
yyyy
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| Occupied By: |
|
| Please check those which apply: |
Deadbolt |
| Smoke
Detector |
| Fire
Extinguisher |
|
Property Visible to Neighbors |
| Sprinklers |
| Gated Community |
| 24 Hour Doorman |
| Security Cameras |
| Swimming Pool?: |
No |
| Yes |
Approved Fence |
| Diving Board |
| Above Ground |
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In-Ground |
| Roof Type: |
ex. "shingle" |
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General Information
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| Please check those which apply. |
| At Home Business: |
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Description:
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| Hazard present for flooding, brush fire, forest fire, landslide: |
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Description:
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| Animals/Pets: |
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Description/Breeds:
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| Property located within 2 miles of tidal water: |
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Description:
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| Property located on more than 5 acres: |
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Description:
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| Trampoline on Premises: |
Yes |
| No |
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Rooms, Attics and Garages |
| Please enter the quantity of each type of unit in your
home. |
| |
Kitchen |
| |
Dining Room |
| |
Living Room |
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Den/Study/Office |
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Family/Recreation Room |
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Bedroom(s) |
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Bathrooms(s) |
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Large Utility/Laundry/Sewing Rooms (Over 150 sq.
ft.) |
|
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Finished Basement (Omit if counted as family/rec
room) |
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Attached 2-Car Garage |
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Large Finished Attic (Over 150 sq. ft.) |
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Partially Finished Attic |
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Partially Finished Basement |
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Brick/Stone Exterior Walls |
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Central A/C |
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Aluminum/Vinyl Siding |
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Large Wall Fireplace |
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Enclosed Porch/Breezeway |
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Clay Tile or Slate Roof |
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Any Other Unit Not Listed Here |
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Half Bath |
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Large Open Porch/Breezeway |
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Standard Fireplace |
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Unfinished Basement |
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Attached 1-Car Garage |
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Built-in 2-Car Garage/Carport |
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Small Utility/Laundry Sewing Rooms (Under 150 sq. ft.) |
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Foyer/Entrance Hall |
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Dressing Room/Walk-in Closet |
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Unfinished Attic |
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Small Finished Attic (Less than 150 sq. ft.) |
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Mudroom (With separate entrance) |
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Brick/Stone Veneer (Front Wall) |
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Dinette or Partitioned Breakfast Nook |
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Any Other Unit Not Listed Here |
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Thank You!
You've completed the
form. If you have any general questions or comments, please enter them in the box below,
then click the submit button. Thank you for considering Bermack, Champion & Lewine. We
will respond to you promptly. |
General
Questions/Comments:
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