Town-Home & Condo - Bob Meyer Insurance Lakeville, Minnesota

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Town-Home or Condo Quote Request Form


Your Full Name:*
Property Address:*
City or Town:*
County:*
State:
Zip Code:*
Email Address:*
Email (again for acuracy):*
Daytime Telephone:*
Other or Cell Phone:
Fax (Optional)
First Named Insureds Date of Birth:*
First Named Insureds Social Security Number:
Marital Status:*	Married Single Seperated
2nd Insureds or Spouse Full Legal Name:
2nd Insureds or Spouse Date of Birth:
2nd Insured or Spouse SSN:
What Year was the Building Built?
Is this home or building under construction?	No Yes
Number of Units in Building:*
Foundation Type:	Basement Slab Crawlspace Other (list in remarks)
Construction Type:*	Frame Concrete Brick/Veneer Stone Other (list in remarks)
Roof Type:	Composition Shingles Wood Shakes Tar/Gravel (Flat Roof) Tile Metal Other (describe in remarks)
Number of Stories:	One 1.5 Two Three
Do you own any animals or pets?*	Yes No
If last questioned was yes, please give details:
Do you own a trampoline?*	Yes No
Number of feet to nearest fire hydrant (Est)?*	Less than 500 feet Less than 1000 feet More than 1000 feet
Number of miles to responding fire dept.	Less than 5 More than 5 Don
Name of responding fire department (if known):
Do you currently have home or renters insurance?*	Yes No
Any Claims in last 5 Years?*	Yes No Unsure
Details of past claims (if applicable)
Rate Your Credit History:*	Excellent Good Average Less than average Poor
Past history of on-time insurance payments:*	Excellent Good Average Poor
Water supply lines in home:	Copper Plastic tubing Galvanized Pipe Some copper & other
Heating System:*	Gas or Propane Electric Other
Electrical:	Circuit Breakers Fuess Not sure
Fireplaces or Wood Stoves:*
Monitored Security Alarm System:*	No Yes
Current or Desired Dwelling Coverage Limit:
Personal Property (Contents) Limit:*
Personal Liability Limits Desired:*	$100,000 $300,000 $500,000 $1,000,000 Not Sure
Policy Deductible Desired:*	$250 $500 $1000 $2500 $5000 Not Sure
Comments/Remarks/Details:
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