Home Insurance Quote

Applicant Name*

First NameLast Name

Applicant DOB?*

Date

YesNo

Co-Applicant Name*

First NameLast Name

Co-Applicant DOB?*

Date

YesNo

What is the corporation's name?*

Please provide corporation name as shown on property appraiser

Property Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

E-mail*

example@example.com or N/A if no email

HO - Residence of InsuredDP - Rental PropertyOther

Masonry - Block or ConcreteFrame - Wood or AluminumOther

9-12 Months5-8 Months0-4 Months

YesNo

Non-Owned Private PropertyOwned Private PropertyMobile Home ParkSenior Mobile Home Park

YesNo

Make of the Home?*

Ex. Fleetwood or Palm Harbor if unsure notate.

Square Footage of Mobile Home*

Customer can also provide length and width

Serial Number of the Home?

Typically located in kitchen cabinet or master closet if unsure notate.

Age of the Mobile Home?*

Structures of the Mobile Home?*

Ex, Attached Sunroom 400 square foot worth 5,000 or unattached shed that is 350 square feet worth 3000. If no other structures are provided put N/A in the field.

YesNo

Specify Further?*

Please note monitored alarms can be ONLY burglary, ONLY fire, or BOTH. Local can simply be smoke detectors or un-monitored alarm.

If Home is new construction, who is the builder?

Only ask this question if home is currently under construction or was very recently finished being built.

Single EntryGated with GuardsKeycode Entry Gated

YesNo

What kind of animal?*

Include species and breed. (ex. a dog; chihuahua)

YesNo

Please detail all losses with locations, dates, amounts, type of damage, and status of claim.*

Ex, Water Damage 5/10/2015 $30,000 Paid Out Claim is Closed.

Year Roof was Installed/updated?*

Roof Type*

Please Describe*

Year HVAC was installed/updated?*

Year plumbing was installed/updated?*

YesNo

Year electrical was installed/updated?*

YesNo

Please retain this completed on the applicants file. If the applicant purchases a policy, this document is required to be sent for signature alongside their applicant and should be saved on the file after signature is obtained.

Customer Signature

Karla Salmon Insurance

1890 W County Road 419 Ste 2030

Oviedo, FL 32765

407-478-8808

www.karlasalmoninsurance.com

Property Insurance Quote Sheet

Basic Information

Determining Policy Form

Discount Questions!

Loss History