The Ted Hartleb Agency
Without the Love, it's just Insurance
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HOME OWNERS QUOTE
Name
*
Address
*
Home Phone
*
Cell Phone
DOB
Social Security Number
DO YOU HAVE INSURANCE NOW?
Yes
No
WHO IS IT THROUGH?
WHEN DOES IT EXPIRE?
HOW MUCH ARE YOU INSURED FOR?
WHAT IS YOUR PREMIUM?
WHEN DID YOU MOVE IN?
WHAT YEAR WAS YOUR HOME BUILT?
IS IT:
Frame
Brick
IS IT:
VINYL SIDING
ALUMINUM SIDING
IS IT:
One Story
Two Story
SQUARE FOOTAGE OF EACH FLOOR
DOES IT HAVE A BASEMENT?
Yes
No
HOW MUCH OF IT IS FINISHED?
IS IT A WALKOUT?
Yes
No
ATTACHED OR DETACHED GARAGE?
NUMBER OF CARS?
ANY OTHER DETACHED STRUCTURES? (SHED, POLE BARN, GARAGE)
ANY DECKS, PORCHES, BALCONIES, OR BREEZEWAYS? (SQ. FT)
POOL OR HOT TUB?
DIVING BOARD?
Yes
No
IS POOL FENSED IN?
Yes
No
DO YOU HAVE DEADBOLT LOCKS?
Yes
No
DO YOU HAVE ATRIUM, PICTURE, BAY OR GREENHOUSE WINDOWS?
DO YOU HAVE SKYLIGHTS, SLIDING OR FRENCH DOORS?
DRYWALL OR PLASTER WALLS?
DRYWALL
PLASTER
AMOUNT OF PAINT, WALLPAPER OR PANELING ON WALLS?
AMOUNT OF HARDWOOD, CARPET, TILE OR VINYL FLOORING?
NUMBER OF BATHROOMS?
DO YOU HAVE A JACUZZI TUB?
Yes
No
SEPERATE FR, LR, Den, Laundry ?
IS YOUR STOVE BUILT INTO YOU COUNTERTOP?
Yes
No
WHAT TYPE OF COUNTER?
DO YOU HAVE A BUILT IN MICROWAVE OR OVEN?
NUMBER OF FIREPLACES?
DO YOU HAVE A WOODBURNING STOVE?
Yes
No
DO YOU HAVE A WET BAR?
Yes
No
DO YOU HAVE A WATER SOFTENER?
Yes
No
DO YOU HAVE CENTRAL AIR?
Yes
No
DO YOU HAVE A CARBON MONOXIDE DETECTOR?
Yes
No
DO YOU HAVE AN INTERIOR SPRINKLER SYSTEM, BURGLAR ALARM OR FIRE ALARM?
DO YOU HAVE ANY CEILING FANS?
Yes
No
ANY UPDATES TO ELECTRIC, PLUMBING, HEATING, ROOF (YEAR)?
HOW FAR AWAY FROM YOUR HOME IS THE NEAREST FIRE HYDRANT?
WHAT FIRE DEPARTMENT RESPONDS TO YOU?
YOUR HIGHEST LEVEL OF EDUCATION?
DOES YOUR SPOUSE WORK?
Yes
No
IF SO, WHERE?
ARE YOU SMOKERS OR NON-SMOKERS?
SMOKERS
NON-SMOKERS
ANY PETS?
ANY CLAIMS FOR DOG BITES?
Yes
No
ANY CHILDREN?
THEIR AGES:
DO YOU HAVE A MORTGAGE?
Yes
No
IS YOUR INSURANCE ESCROWED?
Yes
No
ANY LOSSES TO YOUR HOME OR CLAIMS MADE IN THE LAST 5 YEARS?
DO YOU BELONG TO A CREDIT UNION, AARP, OR COLLEGE ALUMNI?
WHAT DEDUCTIBLE WOULD YOU LIKE?
ANY SECONDARY HOMES, RENTAL UNITS, WATERCRAFT, OR SCHEDULED JEWELRY?
THIS IS NEITHER AN APPLICATION OR A CONTRACT, IT IS FOR INFORMATION PURPOSES ONLY.