HUH Homeowners Insurance Pre-Application

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Homeowner Insurance Pre-Application

Verification Approval

You may either complete the form online below, or click here to download a
printable form in Adobe pdf format that you can complete and fax to us.

To prepare your quote, we will review your claim history. Insurance companies may also require that we confirm your financial stability, but we do not see your credit history. If you agree to these procedures, please check AGREE and add your name.

If you indicate you do not agree, we are sorry, but we cannot provide you an accurate quote at this time.

I AGREE

I DO NOT AGREE

Name

Name(s) as they appear on the mortgage:
Address
How Long:	(if less than 60 days please include previous address below )
City
State		Zip Code
Previous Address:
City
State		Zip Code
How Long:
Home Phone	( )
Work Phone	( )
Cell Phone	( )
Pager	( )
SS#
Date of Birth
Occupation
Home Construction	Masonry Veneer Frame/Siding Stone
	Other
Year of construction:		Age of home: yr(s).
If the house is more than 20 years old, indicate updating of following systems with an F for full replacement or a P for partial update, and indicate the year it was done.
Heating	F P	Year
Roof	F P	Year
Wiring	F P	Year
Plumbing	F P	Year
Roofing Material	Tin Woodshake Composite asphalt shingles
	Other
Number of Bathrooms		full half
Fireplace	Masonry Prefab
Under the Home	Basement Crawl Space Slab
If Basement, what percentage is finished?		%
Does the home have:		Smoke Detectors Dead Bolt Lock Fire Alarm System Burglar Alarm System
Do the fire and burglar alarms sound only in the home, or do they signal/call a central station for help?		In-Home Central Reporting
If the home is in a rural setting, how far to the nearest fire station?		miles
How many feet to the nearest fire hydrant?		500 or less 500 to 1000 more than 1000
Is there a pond, running creek or other large water source on the property?		Yes No
If YES, is it readily accessible by truck or pumping equipment?		Yes No
Your current homeowner insurance coverage limits:
Dwelling Coverage (A)		$
Other Structures (B)		$
Personal Property (C)		$
Loss of Use (D)		$
Personal Liability (E)		$
Medical Payments to Others (F)		$
Have you ever filed for bankruptcy?		Yes No
If yes, what year
Does the home have a swimming pool?		Yes No
	If Yes	In-Ground Above Ground Fenced Unfenced
Does the home have a trampoline?		Yes No
What is your current deductible?		$
What would you like your new deductible to be?		$100 $200 $500 $1000 $2500
Current homeowners insurance company
How long with this company?
Date policy expires
How many losses (claims) have you had in the last five years?
Please explain the loss, the date and the amount paid
Is your homeowner insurance premium paid through an escrow account?		Yes No
Do you currently have or want any of the following optional coverages?
Form 5 (personal property for additional perils)		Have Want
Earthquake insurance		Have Want
Back-up of sewers/drains		Have Want
Flood insurance		Have Want
Specific personal property items insured:
Jewelry:		Limit $
Furs		Limit $
Fine art (with or without breakage)		Limit $
Silver		Limit $
Firearms		Limit $
Collectibles		Limit $
Does the home contain any of the following?
Wood-burning stove		Yes No
Was it professionally installed?		Yes No
Domestic employees		Yes No
Home office/business		Yes No
Do you own any rental property or undeveloped land		Yes No
If yes, who is it insured with?
Form Completed by