Saucon Mutual Insurance Company | HOME OWNER'S QUOTE

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INLAND MARINE INSURANCE

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Home Owner's Quote

Please fax (610/317-0998) or e-mail (info@sauconmutual.com) a copy of your current homeowners policy showing the coverage amounts and coverage forms. This will assist us in poviding you with an accurate quote in addition to the information you provide below.

Name:

Home Phone:

Home Fax:

Email:

Mailing Address:

Mailing Address (Suite#):

City:

State:

Zip:

Township/Municipality/Borough:

County:

Insured Premises (If different):

Insured Address:

City:

State:

Zip:

Township/Municipality/Borough:

County:

Settlement Date:

Selling Price:

Mortgage Amount:

Number of Stories:

Year Constructed:

Ground Floor Square Footage:

Construction Type:

How would you rate the overall condition of the home?

Do you have a fire alarm system?

Do you have...

Smoke Alarms? yes no

Dead Bolt Locks? yes no

Fire Extinguishers? yes no

Do you have a burglar alarm system?:

Is there a fire hydrant within 1000 feet of your property?

yes no

How many miles to the fire department?

Type of Heat?

If oil, where is the tank located?

Do you have a woodburning stove?

yes no

If yes, was it professionally installed?

Do you have a swimming pool?

yes no

If yes, is there a diving board or slide?

yes no

If yes, is it fenced in with a locking gate?

Do you have any pets?

yes no

If yes, what breed and disposition? (If breed is mixed, which breeds?)

Present Insurance Company:

Renewal Date:

Have you filed any homeowners claims in the last three years?

yes no

If yes, please describe the claim and amounts paid out:

If the house is over 20 years old, list the year when the following systems were last updated?

Roof:

Heat:

Plumbing:

Electrical:

Current Coverage Amount:

Dwelling:

Other Structures:

Contents:

Loss of Use:

Personal Liability:

Guest Medical Payments:

Deductible:

Current Annual Premium:

Would you like coverage for...

Sinkhole Collapse:

yes no

Earthquake:

yes no

Law or Ordinance:

yes no

Identity Theft:

yes no

Is property held in the name of a trust?

yes no

If yes, name of trust, grantor, trustee, and beneficiary?

Any children 21 or under away at college?

yes no

If yes, what college and state?

Any other residential properties owned in your name/names?

yes no

If yes, location?

If yes, is it tenant occupied or seasonal for your use only?

Any watercraft owned?

yes no

If yes, what type/horsepower/length?

Any pilot's license or aircraft owned?

yes no

Any valuable personal articles to be scheduled?

yes no

Silverware appraised value:

Firearms appraised value:

Jewelry appraised value:

Fine Arts appraised value:

Furs appraise value:

Please email us your questions, comments or feedback. If your question concerns an existing policy, please provide the respective policy or account number for faster processing.

If you question is concerning a specific quote, please provide as much information as possible for an accurate quote.

NOTE - We will prepare a quote based upon your current policy coverage. Before a coverage is written, we require an interior and exterior inspection of the property.

Please fax (610/317-0998) or e-mail (info@sauconmutual.com) a copy of your current homeowners policy showing the coverage amounts and coverage forms. This will assist us providing you with an accurate quote in addition to the information you provided above.

Saucon Mutual Insurance Company | 528 North New Street, Fourth Floor, Bethlehem, Pennsylvania 18018
E-mail: info@sauconmutual.com | Telephone 610- 868-1800 | Fax 610-317-0998