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  Welcome!
Attention:
Effective Date:
Your Name:
Your Mailing Address: Street

City & State                            Zip
  
E-mail Address:
Daytime Phone #:
Choose One: Please call me with quote premium.
Please send quote via e-mail.
Current coverage: Company:                          Expiration Date:
 
Type of policy desired:
 
Amount of insurance desired:
Homeowners only:
What is the value of your home?

Condo/Renters only:
What is the value of your personal property?

Liability Limit:



Medical Payments:
Valuation of Home:


Personal Property Valuation:
Deductible:
Property Information:
What is the construction type of your home?
In what year was your home built?
In what County/Township are you located?
Distance to the nearest fire hydrant?
What kind of pets do you have?
Do you have a swimming pool?
Yes No
Do you have a trampoline?
Yes No
Do you use a wood burner?
Yes No
Smoke Detector(s) Installed
Home Security System Installed
 
Home Updates:  Enter year updates were made. If year not known, enter "unknown":
Roof:


Wiring:
Plumbing:


Heating:
Optional Property Coverages:
Earthquake Coverage Requested
Flood Coverage Requested
Sewer/Water Backup Coverage Requested
Property Floaters - Indicate limits below:
Antiques:


Coins:


Computers:


Fine Arts:
Furs:


Jewelry:


Stamps:


Tools:
Other Floater Coverage:     Limit of Insurance:
 
Previous Loss Information
Please describe any losses or claims filed on your Homeowners Insurance in the last 3 years:
Be sure to include the date of loss, type of loss and the amount of the claim.
Additional Comments
Please use the box below to enter any additional information you wish to include:
        

 
©2006-2007 Bendetta Insurance Agency, Inc.
Toll Free: 1-800-967-7065    Phone: (330) 494-8400    Customer Service