HomeownersInsurance

     2514 Wylie Ave., Pittsburgh, PA 15219
       Phone: 412-621-5581     Fax: 412-681-5506
           Homeowners Insurance
Please fill out the gray area as well as the tan area to receive an accurate quote.

Name

Phone

Current Address

City

State

Zip

How long at this address?

Email Address

Previous address if less than 2 years:

City

State

Zip

.Employer Bus.Phone

Yrs. with company Yrs.in occupation

Current Homeowners Ins. Policy

Any past losses?

Fire Liability Theft
Details:

Homeowners Insurance Quote Form

Your house was built in

No. of Stories

Structure: Brick Frame Other

Style: Ranch, Split, B-Level, Tri-Level etc.

Part of Row Houses

No.of families

Is there a basement?Is the basement finished?
Game Room Game Room Dimensions (ft.)

Finished attic Dimensions of attic:

No. of bathrooms No. of half-baths/ powderrooms

Garage? Detached Garage size, # of cars

Is there a 3-wall addition to the house? brick frame
Above a basement? # of stories Dimensions

How many porches? Open Enclosed

Dimensions of porches Open

Enclosed

Is there a stoop? Foundation under the stoop?

Dimensions of stoop

No. of Balconys Dimensions of balconies

No. of Decks Dimensions

Breezeway between house & garage? Dimensions

Number of working fireplaces

How many chimneys? How many hearths?

Number of woodburning stoves? Professionally installed?

Central air conditioning? Does it use existing ductwork?
Or separate ducts

Check off BUILT-IN items in the home:

Air humindifier bathroom heater hot tub dishwasher

ceiling fans # of ceiling fans central vacuum system

countertop range domestic solar hot wqter electric air filter

garage door opener garbage disposal water softner

intercom system sauna interior sprinkler system wet bar

security fire alarmsmoke alarms # of alarmswired-in?

open prefabricated fireplace rangehood hood exhaust fan

skylight trash compactor whole house fan deadbolts

exterior lighting swimming pool

Year work last completed on the following:

Roof Plumbing

Wiring Fuses Circuitry

60 amp service 100 amp service

Heating Gas Coal

Steam radiators Electric

What type of roof? shingles Slate Shakes Other

Additional Remarks