• Personal
  • General
  • Building
  • Building, cont.
  • Property

Primary Insured Information

Email *: Name *:
Phone *: Address *:
City, State, Zip *: Occupation *:
Date of Birth *: Social Security Number *:

Spouse Information

Name: Phone:
Occupation: Date of Birth:
Social Security Number:    

General Questions

When did you purchase the building?
Do you have home owners insurance now? YesNo
If yes, who is your current carrier *?
Expiration Date *:
Do you have any dogs *? YesNo
Do you have an alarm system *?
Is the home within 1000 ft of a fire hydrant *? YesNo
Have there been any claims to your home *? YesNo
If so, please explain *:

Building Information:

Building Address*: City, State, Zip*
Year Built*: Number of stories*:
Square Footage*: Roof Type*:
Flat Roof*? Yes No Siding*?  
Build Type (Masonry, Joint Masonry, Frame, etc.)*:
Type of heat*: If Oil, where is the oil tank located?
Basement*: YesNo If yes, finished?
Number of bedrooms*: Number of Baths*:
Pool?* YesNo Fenced in?* YesNo
Diving Board?* YesNo Slide?* YesNo

Building Information (cont.):

Percentage of Carpet, Hardwood Floors, Tile:

Garage: YesNo If yes, please elaborate (detached, attached, one car, two car):

Last time the roof, heat, plumbing and/or electric was updated:

Is the building fully occupied: YesNo If No, please explain:


Personal Property:

Please list Jewelry, Art, Furs to be scheduled and they approximate value:


Please enter any additional information that will help us serve you:




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Regional Insurance Associates © 2011 | p: 215.321.1900 | f: 215.321.1700 | Email