Homeowner's Insurance Form

570.226.4571 amskier@amskier.com

Please complete as much of this form as possible.
Full Name*
A value is required.
Birth Date*
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
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?*



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
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?



If yes, breed

Construction of building



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





Any central fire/burglar alarms



Central sprinkler system



Fireplace or woodstove



Full Basement



Finished Full Basement




Any claims in the last 5 yrs



If yes, date & description
Co Op or condo (if applicable)



Is there a fire hydrant within 1000 feet or less of apartment or residence?




Is fire station within 5 miles of apartment or residence?




Notes

Vehicle information - Optional
Do you own or lease any autos?



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






Comprehensive Deductibles





Collision Deductibles





Towing and Labor




Rental Car





How did you hear about us?
Provide detail in the field below







Comments/Notes