Homeowner’s Quote Questionnaire

Date of Birth:
Date Format: MM slash DD slash YYYY
Today's Date:
Date Format: MM slash DD slash YYYY
Effective Date of Policy:
Date Format: MM slash DD slash YYYY
Purchase Date/Time at Present Address:
Date Format: MM slash DD slash YYYY
Name:
First Last
Marital Status:
Spouse’s Name/2nd Insured’s Name
First Last
Current Insurance Carrier:
Email:
Address:
Street Address Address Line 2 City State ZIP Code
Expiration Date:
Date Format: MM slash DD slash YYYY
Reason for Request:
Please share how you heard about Fox Insurance:
Please let us know who, if so, you have been working with at Fox Insurance:
Phone (Home):
Phone (Work/Cell):
Employer:
Spouse' Employer:
Date of Birth:
Date Format: MM slash DD slash YYYY
Social Security Number:
Spouses' Date of Birth:
Date Format: MM slash DD slash YYYY
Spouses' Social Security Number:
Mortgage:
Have there been any losses in the last 5 years?
Please list date and description.

Any Special Features, or Built-in Terms?
Home Under Construction:
Any Business or Farming Practices conducted on Property? Please explain:
Any trampoline/swimming pools/hot tubs/spas/etc.?
Any animals on property? (list animal type & number; if dogs, include the breed):
Does Anyone Smoke:
Smoke Alarm:
Deadbolt Locks:
Alarm System:

Preferred Deductible:
Any items (Jewelry/furs), or collections to schedule?
Coverages Desired Dwelling:
Personal Property:
Liability:
Medical Payments:
Post Image
Which method of communication do you prefer for one of our agents to reach out to you?

Renovation Years of: