1. HOMEOWNERS QUESTIONS
Fax: 612-888-9653 email: elbroncoins@gmail.com
Name Insured: _____________________________________________________ DOB: _________________
Occupation: ______________________ SSN: _______________________ Phone #: _______________________
Spouse/Additional Insureds: __________________________________________ DOB: __________________
Occupation: ______________________ SSN: _______________________ Phone #: _______________________
Complete address: _________________________________________________________________________
First time Homeowner: Y / N Prior Policy: ____________________________ Expiration Date: ________________
Under construction? Y / N Trampoline? Y / N Dogs? Y / N If yes list: ________________
Swimming pool? Y / N Year built ______________ Purchased price $ ___________________
Purchase date (effective date): _____________ Home style: _________________
Heat type? Electric Gas-forced air Gas- hot water Oil
Updated: Year
Heating (calentador) Complete / Partial
Electrical (circuito electrico) Complete / Partial
Plumbing (Plomeria o tuberia) Complete / Partial
Roof (techo) Complete / Partial
Actual home price (today) $ ________________ Home Sq Footage: ______________
Smoker: Y / N Water backup? Y / N Any losses or claims? Y / N
Basement finished? Y / N If so % finished? ________ Water back up? Y / N
List # of full bathrooms _______________ Half bathrooms ______________
Porch? Y / N Sq ft ____________ Deck? Y / N Sq ft ___________ Garage? Y / N
Attached / Detached One vehicle / Two vehicle Fireplace? Y / N
Bank account (escrow account)? Y / N
Notes:
Co: _____________________ Bill to escrow account: Y / N Bank Name: ______________________
Quote #: _________________ Loan No: __________________ Address: _________________________
Down Payment: ___________ Loan info: _________________ _________________________________
Bill Plan: _________________ Appraisal Attached: Y / N