Dean Insurance welcomes your comments and suggestions!

Name of Insured	DOB	Cell Phone Number	Work Phone Number	Email Address

 

Home Phone Number
Address
Address Con't
County
Zip Code
Effective Date
Present Carrier
Policy Type	Homeowner      Renter     Condo Owner      Rental Property      Multi-Unit Rental Property     Vacant House
Construction Type	Frame             >75% masonry
Protection Class	Well Water       City Water
Owner or Tenant Occupied
How Many Family Members
If Apt or Condo, How Many Units
Year Built
# of Stories
Single Family Home or Townhouse
If a townhouse, middle or end unit
Years at Current Residence
Miles to Fire Department
Feet to Fire Hydrant

Wiring {if home is over 30 years old}
Heating {if home is over 30 years old}
Plumbing {if home is over 30 years old}
Roof {if home is over 30 years old}
Dweling Value
Personal Property
Personal Liability
Deductible
Swimming Pool
Trampoline
Pets
Other Structures
Loss of Use
Medical Payments
Specialty Forms
Woodstove, Fireplace Insert, or Pellet Stove and location
Smoke Detectors on All Levels
Fire Distinguisher
Sprinkler System	Full             Partial
Central Station Alarm	Fire            Burglary            Both
Dead Bolt Lock on All Exterior Doors, Including Sliders	Yes            No
Do You Belong to a Homeowners Association?	Yes            No
Have you had your Homeowners Insurance Cancelled within the last 3 years, if so why?
Have you had any Homeowners Losses reported to the company in the past 3 years even if no payout, if so why?

 

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