Homeowner's Insurance Form

Please complete as much of this form as possible.
Full Name*	A value is required.
Birth Date*	- mm/dd/yyyy A value is required.Invalid format.
Social Security Number*	Your social security number can be submitted over the phone by calling 570-226-4571 and asking for a Personal Agent.
Spouse/Partner Full Name
Birth Date	- mm/dd/yyyy Invalid format.
Social Security Number	Your social security number can be submitted over the phone by calling 570-226-4571 and asking for a Personal Agent.
Do you rent or own?*	Rent Own
Email Address*
Additional Email Address
Home Phone*	A value is required.
Work Phone
Resident Address*	A value is required.

Mortgage holder information, if applicable (name, address, city, state, zip, phone)
Current Amount of Insurance or Purchase price*	A value is required.
Any decks or porches	Yes No
If Home is over 20 years, please answer the questions below:
Year roof replaced?
Electrical update?
Plumbing update?
Heating update?

Any items to schedule (jewelry, fine arts) - description, value.
Any dogs?	Yes No
If yes, breed

Construction of building	Frame Masonry Brick
How many floors
How many floors in the building, if applicable
Year Built	A value is required.
Sq ft of apartment or residence	A value is required.
Central heat type	Gas Oil Electric Steam
Any central fire/burglar alarms	Yes No
Central sprinkler system	Yes No
Fireplace or woodstove	Yes No
Full Basement	Yes No
Finished Full Basement	Yes No Does not apply
Any claims in the last 5 yrs	Yes No
If yes, date & description
Co Op or condo (if applicable)	Co Op Condo
Is there a fire hydrant within 1000 feet or less of apartment or residence?	Yes No Unknown
Is fire station within 5 miles of apartment or residence?	Yes No Unknown
Notes

Vehicle information - Optional
Do you own or lease any autos?	Yes No
Drivers information state issued, license number
Driver 2 information state issued, license number

Year
Make
Model
Vin Number

Year - Vehicle 2
Make - Vehicle 2
Model - Vehicle 2
Vin Number - Vehicle 2

If the following information is not known, please leave blank.
Liability Limits	100/300/50 250/500/100 Single limit 100,000 Single limit 300,000 Single limit 500,000
Comprehensive Deductibles	$100 $250 $500 $1000
Collision Deductibles	$100 $250 $500 $1000
Towing and Labor	$25 $50 $75
Rental Car	$30 $40 $50

How did you hear about us? Provide detail in the field below	Radio Advertisement Friend Camp Search Engine Other
Comments/Notes