Home & Auto Quote Sheet
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3Taylor-Palmer Agency, Inc.
Home & Auto Quote Sheet
Date: ______________
Home #: ______________
Work #: ______________
Cell #: ______________
Name: _________________________ DOB: __________ Occupation: ____________________
Name: _________________________ DOB: __________ Occupation: ____________________
Mailing Address: ___________________________________________________________________________
Email: _____________________ Email: _____________________ Consent to Insurance Score?* Yes No
How did you hear of us? _____________________________________________________________________
Home
Currently Insured? Yes No Insurer: _____________________________________ Expiration: _________
Previously Cancelled? Yes No
Any Losses? Yes No
Years with Insurer: ____
Loss/Cancel Info: ___________________________________________________________________________
__________________________________________________________________________________________
Location Address: ________________________________ Former Address: ____________________________
Years at Current Address: ____ Year Built: ____ Number of Families: ____ Business Exposure? Yes No
Mortgagee: ________________________________________ House for Sale? Yes No
Living Area: _______________ Stories: _______ Attached Structures: ________________________________
Type of Central Heat: ________________ If Oil, Tank Underground? Yes No On Concrete? Yes No
Wood Stove/Furnace? Yes No Supplemental Heat: ________________
Any Smokers? Yes No
Year Utilities Updated (If over 25 years old) - Heat: ____ Plumbing: ____ Electrical: ____ Roof: ____
Smoke Alarm? Yes No
Dead Bolt? Yes No
Fire Ext? Yes No
Security System? Yes No
Carbon Monoxide Detectors? Yes No
Detached Structures? Yes No _____________________________________________________________
Swimming Pool? Yes No
If Yes, is it fenced? Yes No
Trampoline? Yes No
Tree House? Yes No
Skateboard Ramp? Yes No
Other: ______________________________
Animals? Yes No Type: _________________________________________________________________
Desired Dwelling Coverage (Replacement Cost): ______________________
Deductible: _____________
Additional Coverage Desired For:
Silver over $1,000 - Yes No
Guns over $1,000 - Yes No
Jewelry - Yes No
Boats - Yes No
Motorcycle or Snowmobile - Yes No Computers - Yes No
Other Items - Yes No
Other Owned Locations - Yes No ___________________________
__________________________________________________________________________________________
Additional Info: ____________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
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Parent category: Financial