Links Insurance Agency

General Information

Name:
Address:
City:	State: ZIP:
E-mail:
Phone Day:	Night:
Best time to call:
Occupation:
SSN:

Current Homeowners Insurance Company (not agency):

Is This Home Currently Insured:	yes no
Company Name:
Policy Exp. Date:
Amount Insured For:	$
Premium:	$

Home Information

How long at present address:		# of claims in last 5 years:
Bankruptcy? If so, when? If none, leave blank
Sq. footage of home: (excluding garage and basement):		Year home was built:
Any roomers or borders?	yes no	Any business conducted on premises?	yes no
Any full-time residence employees? (Housekeeper, etc.)	yes no
Any animals or exotic pets? (Akita, Doberman, Rottweiler, German Shepard, Pit Bull, etc.):	yes no	MUST INDICATE BREED AND/OR MIX BREED
Are you located in an area classified as a Flood Zone?	yes no
Is your home located within 4 miles of ocean or bay?	yes no	Distance:
Is your home located within 1 mile of a river, creek, or other body of water?	yes no	Is Flood Insurance required?	yes no
Is there a satellite dish?	yes no	Is it protected against lightning?	yes no
# of Families:	1 2 3	Year Built:
Construction:	Frame Brick
IS THERE ANY EFIS, STUCCO SIDING ON THE HOME?	yes no
Are you the Owner/Occupant?	yes no	If No, is it: Seasonal? Non-Seasonal?
Is this your Primary home?	yes no	If No, is it Secondary?	yes no
Is home within 1,000 feet of a fire hydrant or within 5 miles of a fire department?	yes no
Pool and/or Hot Tub?	yes no	Above Ground? In Ground?
Is the Pool fenced & locked?	yes no	Is there a Diving Board and/or Slide?	yes no
Do you own a Trampoline?	yes no
Are there smoke alarms?	yes no	Local: Central Station:
Are there fire alarms?	yes no	Local: Central Station:
Is there a theft alarm?	yes no	Local: Central Station:

Structure Information

Type:	Construction:	Roof:	Foundation:	Garage:

Age of roof (yrs):

Features

Bathrooms:	Basement:	Deck/Porch/Patio:	Fireplaces:
# of Full: # of Half:	Sq. Ft:	Deck Sq. Ft: Porch Sq. Ft: Screened Patio Sq. Ft:	# of Chimneys: # of Hearths:

Additional Features

Heating System:	Central Air:	Central Vac:	Security Alarm:	Fire Alarm:	Smoke Detector:
	yes no	yes no			yes no

Additional Comments:

Please give any additional comments about the coverage you desire:

Do you own any other property? yes no

If so, please provide location and current insurance information below:

Do you wish to upgrade your coverage? yes no

Do you have any valuable items that need to be specially scheduled?
(i.e. jewelry, furs, fine arts, etc.) yes no

Items:

If you are concerned about coverage for a specific item or exposure,
please explain:

Describe any homeowners claims paid out in the past 5 years:
( prior, current, or new locations )

Has Applicant/Co-Applicant Had Any Foreclosures, Repossessions Or Bankruptcies? yes no If Yes, Please Indicate Year: