Weis Insurance Agency, L.L.C.

Weis Insurance Agency, L.L.C. - Home Quote

WEIS Insurance - Home Insurance Quotation

PLEASE NOTE: Required fields are in red.
Fill these fields out to obtain accurate pricing, any indication of rates provided are subject to underwriting,
verification of information and acceptance by the Insurance Company
(see disclaimer notes and information about this form.)

HOME OWNER INFORMATION

Applicant:
S.S #:
D.O.B. (MM/DD/YY)
Status:

HOME CO-OWNER INFORMATION

Applicant:
S.S #:
D.O.B. (MM/DD/YY)
Status:

DAYTIME / EVENING PHONE NUMBERS

Home Phone:
Work Phone:
Cell Phone:
Best Time To Call:
E-Mail:

ADDRESS INFORMATION

Legal Street Address:
City:
County:
State:
Zip:
Directions:
Previous Address If Less than 1 Yr.:

HOME INSURANCE - UNDERWRITING INFORMATION

Policy Type :		# of Units :
Year Built:		Ground Floor Sq.Ft.:
Total Rooms:		LeinHolder:
Year Purchased:		Purchase Price:
Yr.Last plumbing update:		Drains:
Electrical System:		Yr. Last Update:
Central Alarm:		Air Conditioning:
Heating:		Yr. Last Update:
Wood Burning Stove:		# of Fireplaces:
# of Chimneys:		# of Hearths:
Garage:		# of Car Garage:
Swimming Pool:		Pool Fenced In:
Size of Decks (sq.ft.):		# of Bathrooms 2 HalfBaths=1 Full Bath:
Mine Subidence Area:		Flood Area:
Responding Fire Dept.:		Distance to Fire Dept.:
Distance to Hydrant:		# of Corners on the home:
Any bathrooms adjoin bedrooms:		Any Hardwood, Slate, Marble or Quarry Tile Floors(Over 70 sq.ft.):
Any Stained, Varnished Woodwork throughout including Baseboards, Windowsills or doors:		Any Brick or Stone Exterior Walls:
# of Aluminum Awnings:		# of Canvas Awnings:
Any Hinged Shutters:		Trampoline on Premises:
Fences:		Linear Feet of Fence:

STORIES	CONSTRUCTION	FOUNDATION	ROOF
1-Story 1 1/2-Story 2-Story Split Level Bi-Level Tri-Level	Frame or Stucco Masonry Mostly Masonry & Frame Mostly Frame & Masonry	Full Basement Partial Basement Basement Type If Partial - enter % If Partial - enter sq.ft. finished Crawl Space Slab	Asphalt Shingle Wood Shingle Tile or Slate Other Age of Roof (Yrs.)

BUILT-INS (Check All That Apply)
Whole House Fan Roof Exhaust Fan Central Vacuum Counter Top Range Oven Dish Washer Range Hood	Trash Compactor Wet Bar Garbage Disposal Microwave Kitchenette Water Purifier Water Softener	Sky Lights Hot Tub Jetted Tub Sauna Bath Room Heater Electronic Ait Filter Fire Extinguisher	Smoke Alarms Alarm Systems Carbon Monoxcide Detector Deadbolts on ALL outside Doors # of Ceiling Fans # Elec.Garage Door Openers

SPECIALTY ROOMS (Check All That Apply)
Den Excerise Room Library Office Sun Room Study	Rec Room Family Room (Addition to Living Room) Great Room (Over 300 sq.ft.)	Formal Dining Room (not dining area) Large Foyer (Over 70 sq.ft.) Laundry Room (Over 70 sq.ft.)	Other Specialty Rooms

Prior Losses Past 5 Yrs.:
If any Business is being conducted on the premises, please describe:
Bankruptcy Ever Filed:

CURRENT INSURANCE INFORMATION

Insurance Carrier:
How Long:
Expires (MM/DD/YY):
Deductible:
Current Premium / Period (Monthly or Annual):

Current Insured Values
Dwelling :		Personal Liability :
Personal Property :		Medical Payments :
Personal Injury :		Scheduled Property :
Flood Coverage :		Other Coverage : (Business/Hobby/Farm)

Other Coverage or Special Needs

Coverage & Values Requested
EarthQuake Coverage:		EarthQuake Deductible:
Sewer/Drain BackUp:		Back Up Deductible:
Replacement Cost on Home:		Replacement Cost on Contents:
Liability Limits:		Medical Limits:
Scheduled Personal Property (Jewelry, Guns, Furs, Cameras, Collectables, Sporting Goods, Etc.) Itemize and include dollar value of each item.