Neal Insurance Agency- Homeowners Quote Sheet

          Name:   Marital Status: Single Married Widow   Phone Number:

          Mailing Address:

          Social Security Number:      Date of Birth:

          Spouse Name:      SS#:          DOB:

        Home Information

          Property Address:

          Year home was built:          Square Footage:      Age of Roof:  Type of Roof: WPI-8? Yes No

          Construction type of home:  Brick Veneer Frame Stucco

          Home located:   inside city limits            outside city limits

          Feet from fire hydrant:   Miles from fire station:   Number of bathrooms:   Number of bedrooms:

          Number of fireplaces:     Garage: 1 Car 2 Car 3 Car 4 Car      Is it: attached  detached    Name on tax roll:       

        Does your home have any of the following:

         ATV   Trampoline   Pool  Diving board/slide      Acreage  How many? Usage of land?

         Animals What kind? What breed?    Alarm System  Do you have a certificate? Yes No

        Outbuilding Information

         Year outbuilding was built:  Square Footage:    Construction type of outbuilding:   Brick Veneer Frame Stucco    Amount of coverage:

         Have there been any claims in the past 5 years:

        Have there been any updates:

          Plumbing:      Heating:   Electricity:

        Prior Insurance Information:

         Prior Insurance: Yes No     Prior Insurance Company:   Coverage Amount:   Expiration Date: