Class Act Insurance Services

Land Lord Insurance Quote Request
1-4 Units
Best Viewed in 800x600 Screen Resolution

Reason for insurance request:
New purchase Current owner with no prior insurance
They are Cancelling my Account Account is going to Non-Renew Searching for a better price

First Name*:		MI:	Last Name*:	Suffix
Property Street Address*:
City*:			State:	Zip Code*:
Home Telephone*:			Work Telephone:	Fax Telephone:
Email Address: (If you will like an email response)
Occupation:
Prior Insurance company Expiration: Example 08/20/1970
Property Information
Type of Dwelling Number of Buildings
Year Built : Square Feet: # of Families:
Years at residence:			# of stories/floors:
# of bathrooms: ( Please include any special items, such as marble or hot tubs)
Interior Partitions (Please include % of house. Example, Drywall 80% Brick 20 ,Interior Partitions options: Drywall, Plaster, Block, Brick, Studs Only, and Textured Sheet Rock.)
Type of Foundation:			Exterior Wall
Floors: (Please include % of house. Example, Carpet 80% , Hardwood 20% Floor options: Hardwood, Carpet, vinyl, slate, carpet over hardwood, tile, marbel, and stone..)
Type of Roof:			Garage:
Interior Walls (Please include % of house. Example, Paint 80% Brick 20%. Interior Wall options: Paint, avg paper, ornate paper, grass paper, plywood, heavy wood, millwork, knotty pine, ceramic tile, brick, cork, stone, mirrors, book case wall, stucco, marble tile, terrazzo tile, and carpet.)
Distance to Fire Hydrant: List any dogs: (Include type of breed)

Please list any other items that may add value to your home, such as french doors, wet bars, fireplace, spiral stair case, detached structures- pool/gazebo/cabana/hot tub/sauna/sheds.
Types of renovation		Year	Partial repair	Completed
Wiring	None
Plumbing	None
Heating	None
Roofing	None
Exterior Paint	None
Additional Underwriting Questions
1. Does the dwelling have copper wiring, circuit breaker and thermostatically controlled heating system?				Yes	No
2. Does insured have any claims in the past 3 years or any unprepared damage/dispute from any pending claims?				Yes	No
3. Is the dwelling located in or near brush/forested/landslide area?				Yes	No
4. Does dwelling have any remodeling or construction performed without permit or undergoing extensive remodeling, renovation?				Yes	No
5. Does the dwelling have trampoline on premises?				Yes	No
6. Does dwelling have pool/spa not completely fenced or with slide/diving boards?				Yes	No
7. Does insured have any vicious/protective dogs or dogs with bite history and requests animal liability?				Yes	No
8. Is dwellings owned/titled under business or financed by private parties/trustees or with more than 2 mortgagees?				Yes	No
9.Is there any type of business performed on permises including child care?				Yes	No
10. Has the roof been replaced within the last 15 years (within 25 years if tile roof)?				Yes	No
11. Have you had any coverages declined, cancelled, or non-renewed in the last 3 years? If yes, please explain:				Yes	No
12. Have you had any foreclosures, repossessions, or bankruptcy in the last 5 years? If yes, please explain:				Yes	No
13. Is the property on more than 5 acres?				Yes	No
14. Do you own any recreational vehicles? If yes, please list:				Yes	No
15. Have you been convicted of any degree of arson?				Yes	No

Levels of Coverages

Liability:*		Coverage Limit Per Occurence
Deductible:*
Guest Medical Payments Coverage:*

Addition Comments:
Please let us know the best time to contact you?
Referred by:

IMPORTANT NOTE: This form is provided as a convenience to you. We will make a good faith effort to obtain competitive quotes for your review. Depending on the type of business, we may require more information and will contact you if necessary. Your submission of this form DOES NOT guarantee that any binding offers will be forthcoming from insurers we represent.

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