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Home Owners Quote Request 2016-12-13T12:10:35+00:00

HOME OWNERS INSURANCE
QUOTE REQUEST

We at Hudson & Muma believe that it is important to offer our customers the most up-to-date technology available which will enhance the service they receive. It is because of this commitment that we are offering this form to aid in generating accurate applications and forms quickly and efficiently!

Remember, without complete information, we may be delayed in producing your quote, so please complete ALL applicable fields.

SUBMITTING THIS FORM YOU ARE AGREEING TO THE CONDITION THAT NO MATERIAL CHANGE WILL BE MADE TO YOUR POLICY UNLESS AND UNTIL YOU RECEIVE CONFIRMATION OF THAT CHANGE FROM A HUDSON & MUMA ASSOCIATE OR AN ASSOCIATE THAT THE INSURANCE COMPANY WRITING THE COVERAGE.
* Indicates required fields


Quote Effective Date:


Insured Information

Type of Customer*:
Personal CustomerCommercial Customer









Preferred Method of Contact:

Previous Address:
(if moved within the last 2 years or if home is
a new purchase)



Insured Birth Date:

Occupation*:

Insured's Education:

Spouse:

Spouse Birth Date:

Spouse Occupation:

Spouse's Education :

Member of any Associations or Clubs (possible discount):
(e.g. Alumni, Chamber of Commerce, Trade Assoc.)

 


 

Current Insurance:

Current Insurance Company:

If NONE, is this:

Prior Policy Number:

Prior Policy Expiration Date:

Has Your Insurance Ever Been Cancelled or Non-Renewed?YesNo

If Yes, Why?:

 


 

Property Information:

Purchase Date*:

Property Address(if different from above):

Type of Residence*:

Site Access*:

Number of Families*:

Style:

Year Built*:

Number of Stories*(different from "STYLE"):

Occupancy*:

Current Replacement Cost Insured for:

Estimated, Current Market Value:

WALL HEIGHT:

"%": Height(ft.):

Fire Hydrant w/in 1000 Feet?:YesNo

Visible From Other Dwellings?:YesNo

 


 

REPLACEMENT COST INFORMATION:

Construction Material*:

Exterior Wall Material 1*:

Exterior Material Percentage 1*:

Exterior Wall Material 2:

Exterior Material Percentage 2:

 


 

Roof Style/Slope 1*:

Roof Style 1 Percentage*:

Roof Style/Slope 2:

Roof Style 2 Percentage:

Roof Style/Slope 3:

Roof Style 3 Percentage:

Roofing Cover 1*:

Roofing Cover Percent 1*:

Roofing Cover 2:

Roofing Cover Percent 2:

Roofing Cover 3:

Roofing Cover Percent 3:

Roof Shape 1*:

Roof Shape Percentage 1*:

Roof Shape 2:

Roof Shape Percentage 2:

Roof Shape 3:

Roof Shape Percentage 3:

 


 

FINISHED Living Area of Dwelling:(Do not include finished basement, built-in garage area or lower level unfinished area in the finished living area)

 


 

Construction Type:

 


 

Foundation Type and Percentage:

Type: "%":
Slab at Grade:
Basement Below Grade:
Basement Daylight:
Basement Walkout:
Crawlspace, Unexcavated:
Crawlspace, Excavated:
Pier:
Hillside:
Hillside Slope:

Foundation Material and Percentage:

Type: "%":
Stone:
Concrete:
Brick:
Block:
Fieldstone:
Wood:

Basement Depth:

Number of Basement Levels:

Number of Basement Stairways w/Railing:

Number of Basement Wide Stairways w/Railing:

Basement Square Feet:

Finished Basement Square Feet:

Basement Finish & Percentage:

Type: Total Number:
Standard Finish:
Custom Finish:

 


 

Garage Type*(Ctrl or CMD + Click for multiple selections)

 


 

A NOTE ABOUT GRADES:
Throughout this form you will see different Construction "Grades", such as:
1. Builders Grade -
The quality of the finish and fixtures is that found in builder's standard spec houses - basically "standard" features, laminate or solid surface countertops.
2. Custom Grade - The quality of the finish and fixtures is a level above Builders Grade - simulated marble or high end solid surface counters, solid wood cabinets and drawers, etc.
3. Deigner Grade - The quality of the finish and fixtures is top end. Marbles, granites, exotic woods and the highest quality appliances. There is help available where you see the "?" icon.

 


 

Number of BASIC Kitchen(s):

Number of BUILDER Kitchen(s):

Number of CUSTOM Kitchen(s):

Number of SEMI-CUSTOM Kitchen(s):

Number of DESIGNER Kitchen(s):

Number of LUXURY Kitchen(s):

Number of COMMERCIAL Kitchen(s):

 

Full Baths:

Number of BASIC FULL Baths(s):

Number of BUILDERS FULL Baths(s):

Number of CUSTOM FULL Baths(s):

Number of SEMI-CUSTOM FULL Baths(s):

Number of DESIGNER FULL Baths(s):

Number of LUXURY FULL Baths(s):

HALF Baths(sink and toilet) (See help under Full-Baths for guidelines):

Number of BASIC HALF Baths(s):

Number of BUILDERS HALF Baths(s):

Number of CUSTOM HALF Baths(s):

Number of SEMI-CUSTOM HALF Baths(s):

Number of DESIGNER HALF Baths(s):

Number of LUXURY HALF Baths(s):

THREE-QUARTER Baths(sink, toilet and shower) (See help under Full-Baths for guidelines):

Number of BASIC 3/4 Baths(s):

Number of BUILDERS 3/4 Baths(s):

Number of CUSTOM 3/4 Baths(s):

Number of SEMI-CUSTOM 3/4 Baths(s):

Number of DESIGNER 3/4 Baths(s):

Number of LUXURY 3/4 Baths(s):

 


 

HEATING TYPE:
(Ctrl or CMD + Click for multiple selections)

Other, Describe:

HEATING DELIVERY TYPE:
(Ctrl or CMD + Click for multiple selections)

Other, Describe:

COOLING TYPE:
(Ctrl or CMD + Click for multiple selections)

FIREPLACES:

Zero Clearance(#):1234

Single:1234

Double:1234

Triple:1234

Gas:1234

Free-Standing Wood Stove:1234

Wood Pellet Stove:1234

 


 

EXTERIOR ATTACHED STRUCTURES:

Exterior Attached Structure 1:

Exterior Attached Structure 1 Count & Sq Ft:

Exterior Attached Structure 2:

Exterior Attached Structure 2 Count & Sq Ft:

Exterior Attached Structure 3:

Exterior Attached Structure 3 Count & Sq Ft:

Exterior Attached Structure 4:

Exterior Attached Structure 4 Count & Sq Ft:

 


 

SPECIAL EXTERIOR FEATURES:

Type: Total Number:
Atrium Windows:
Stained Glass Window (small)
Stained Glass Window (large)
Picture Windows
Exterior Storm Shutters
Atrium Doors
Sliding Glass Doors
Solar Panels
Bay Windows
Bow Windows
Small Skylights
Large Skylights

 


 

INTERIOR PARTITIONS:

Type: % of Total:
Drywall
Drywall Textured
Plaster
Plaster Horsehair
Block

 


 

INTERIOR WALL COVERING:

Type: % of Total:
Paint
Foil Wallpaper
Vinyl Wallpaper
Ceramic Tile
Sheet Paneling
Solid Wood Panelling
Tongue and Groove
Millwork
Bookcase Walls
Mirrors
Knotty Pine Panelling

 


 

CEILINGS:

Type: % of Total:
Drywall
Acoustic Tile
Plaster
Wood
Tongue and Groove
Millwork
Mirrors
Tin

 


 

FLOOR COVERING:

Type: % of Total:
Hardwood
Vinyl
Ceramic Tile
Marble Tile
Parquet
Slate
Carpet Over Hardwood Acrylic/Nylon
Carpet Over Hardwood Wool/Berber
Wall to Wall Carpet- Acrylic/Nylon
Wall to Wall Carpet- Wool/Berber
Plank
Laminated
Rubber
Other

Flooring, Other Describe:

 


 

SPECIAL INTERIOR FEATURES:

Type: # or SqFt
Attic Finished(Sq ft.)
French Doors(number)
Hot Tub(number)
Jacuzzi(number)
Metal Spiral Stair(number)
Wood Spiral Stair (number)
Vanity(number)
Wet Bar(number)
Indoor Swimming Pool(number)
Central Burglar System(Percent)
Central Fire Alarm System(Percent)
Interior Sprinkler(Percent)
Intercom System(Percent)
Central Stereo System(Percent)

 


 

Activated Central Alarm?
YesNo

If so, Alarm Company Name:

Usual Protective Devices?
(Home is equipped with all of the following protective devices:
Smoke Detector, Fire Extinguisher and Dead Bolt Locks.):
YesNo

Automatic Whole Dwelling Water Shut-Off System?
YesNo

Automatic Whole House backup Generator?
YesNo

Any Day Care or Other business conducted on Premises?
YesNo

Any Additional Features (Describe and Include Value)?

Additional Feature Total Replacement Cost:

 


 

HOME UPDATES*:

(Use original construction date if no update in category)

System: Year:
Plumbing*
Heating & AC*
Electrical*
Roof

 


 

SPECIFIC ITEMS AND "SCHEDULED ITEMS":

(we will eventually need a list of items with Serial Numbers and separate value and possibly appraisals and or bills of sale)

Type: Total $ of Items:
Jewelry
Silver
Firearms
Fine Arts
Computer
Mobile Phones
Collectibles
If Collectibles,Describe

 


 

Liability Limit*:

 


 

Deductible:

 


 

First Mortgage?YesNo

First Mortgage Name and Address

 


 

2nd Mortgage or Other Additional Interest?YesNo

Interest Type:

Second Mortgage/Additional Interest Name and Address

 


 

Please Describe Claims you've had withing the last Five Years (include amounts paid):

 


 

NOTES:

 


 

Referred By:

Who Writes Your Life Insurance:

 


 

Attachments:

If you have pictures, floor-plans, improvement invoices, etc, attach here.


Name of person completing form:*

Confirmation Email Address:*

(We need this to send you a confirmation receipt for this form.)