Dunn & Associates Insurance, Inc.
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Homeowners Form



Personal Information
Name: 
Address: 
City:    State:    Zip: 
Day Phone:    Night Phone: 
Email Address: 
Other Adults in  Household?  Yes No

Current Homeowners Insurance Information
Company Name (not  agency): 
Policy Expiration Date:  Premium Amount:  $
Amount Insured For:  $
Policy Type:  Primary Secondary
Reason For Cancel/Non- renewed: 
OR Closing Date: 
Do you have flood  insurance?  Y N
Current auto carrier:  Expiration Date: 

Home Information
Ground Floor Sq. Footage (excluding garage - living area only):
 		 sq. ft.    # of Claims In Last 3 Years:
House Condo Apt Townhouse Duplex
Year Purchased:     Purchase Price:

Protection Devices
Monitored Security
Alarm? 		 Y N
Distance to Fire  Dept/District:   (miles) Distance to hydrant:   (feet)

Structure Information
Type Construction Roof Foundation Garage
    Age of roof: yrs.  

Update Information
If house is over 25 years, provide dates of updates
Electric:   Circuit Breakers: 
Heating:    Plumbing: 
Hot Water Heater: 
Roof Type:    Age: 
*If no updates, will need Contractor Inspection Report completed

For Townhouses and Condos
# Units in building?     End Unit     Middle Unit
Unit Between Fire Walls?  Y N
Number of floors:    On What Floor? 
Security?    Shutters? 
Additions and Alterations  Value: 

If you own a pool
In ground $    Above Ground $ 
Fenced $    Screened $ 
Screened Area Attached To  House?  Y N
Same Roof line?  Y N

Miscellaneous Information
Any detached  buildings? 
Any business done in  home? 
Any dogs on premise? Species? 
Any bite history? 
Watercraft? 
Scheduled Items:  (Jewelry, Home Computer System, Antiques, Collections, etc.)
Is personal umbrella  liability coverage  needed??  Y N

Additional Comments
Please make any additional comments you feel necessary for this quotation. If you have additional information where there was not enough room, please enter it here.
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Home :  About :  Staff :  Personal Coverages :  Business Coverages :   Financial Coverages :  Employee Benefits : 
Individual Life & Health : Contact


Dunn & Associates Insurance, Inc.

Phone: (386) 255-2477

324 W. International Speedway Blvd.

Fax: (386) 255-3573

Daytona Beach, FL 32114-4289

Email: info@dunn-insurance.com

© Dunn & Associates Insurance, Inc.