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Homeowner's Insurance Quotation WorksheetFrom State of Wisconsin Publication Consumer's Guide to Homeowner's Insurance. Applicant: ______________________________________________________________ Address of property to be insured:____________________________________________ Number of losses in last 3 years if covered by homeowner's or fire insurance: ______________ Dwelling:Number of apartments or households in building: _____ |
| Construction (frame, brick, etc.) Number of Stories Number of Rooms |
__________ __________ __________ |
Total Square Feet Age of Dwelling Age of Roof Age/Type of Furnace |
__________ __________ __________ __________ |
Major Options Central Air Cen. Vacuum Cen. Bur. Air. Smoke Dec. Other |
__________ __________ __________ __________ __________ |
| Owner Occupant | ____ Yes | ____ No | Current Dwelling Replacement Cost | __________ |
| Inside City Limits | ____ Yes | ____ No | Current Market Value of Dwelling & Land | __________ |
| Outside City Limits | ____ Yes | ____ No | Purchase Price of Dwelling | __________ |
| Name of Fire Department _______________________________________________________ Distance from Hydrant/Station ____________ |
| Cost of Your Insurance ____________________ | Annual Premium ____________________ |
| Property Coverage & Amount (% of replacement cost) | Insurer ____________________ | Insurer ____________________ | |
|---|---|---|---|
| A. Dwelling | ___________ | $ | $ |
| B. Appurtenant Structures (detached garage, shed, etc.) | ___________ | $ | $ |
| C. Unscheduled Personal Property | ___________ | $ | $ |
| D. Additional Living Expense | ___________ | $ | $ |
| Liability Coverage & Amount | |||
| E. Personal Liability (bodily injury and porperty damage) | ___________ | $ | $ |
| F. Medical Payments | ___________ | $ | $ |
| Deductible Amount | $ | $ | |
| Scheduled Personal Property | $ | $ | |
| Other Coverage(s) | $ | $ | |
| Total Annual Premium | $ | $ | |
| Installment Charges | $ | $ | |
| Total Annual Cost of Homeowner's Insurance | $ | $ | |
| Return to Consumer's Guide to Homeowner's Insurance Publication |
| Updated: April 28, 1997 |
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