Employment Opportunities with Haines & Haines/T.C. Irons

Get a Quote for Personal Homeowners Insurance

OWNER / RENTER INFORMATION
Name Date of Birth   Occupation  SS#   Spouse Name (if applicable)   Spouse Date of Birth   Spouse Occupation  Spouse SS#
# of Consecutive Weeks in the Year Home is NOT Occupied
Do You Own Other Residential Property?	Y N
If You Own Other      Property, Explain
Do you Own Any Pets?	Y N
Have Pets Bitten Anyone?	Y N
Type and Breed (i.e. dog/poodle)

 

LOCATION INFORMATION
Address of Property City State       Zip -- NJ PA NY DE
# of Bedrooms
# of Baths
Do You Own or Rent This Property?	OWN RENT
Is Home / Building Under Construction?	Y N
Date Moved in or Planning Move in

 

CONSTRUCTION INFORMATION
Type of Residence	***SELECT*** Single Family 2 Family 3 Family 4 Family Condo Co-op Apartment Townhouse Rowhouse Other (Complete Below)
Other (Type of Residence)
Construction Type	***SELECT*** Brick Frame Masonry Veneer Other (Complete Below)
Other (Construction Type)
Roof Type	***SELECT*** Tar Slate Wood Rubber Rolled Metal Other (Complete Below)
Other (Roof Type)
Is Roof Flat or Sloped?	FLAT SLOPED
If a House - Is It Attached?	No 1 SIDE 2 SIDES
Year Built
# of Floors (Excl. Basement)
Sq Ft of Living Space (Excl. Basement & Garage)
If a House - Is There a Basement?	Y N       N/A
Is Basement Finished?	Y N       N/A
Sq. Ft. of Basement (if applicable)
# of Apartments/Units (If Building)
PROPERTY UPDATES ROOF (Updated) ELECTRIC (Updated) HEATING (Updated) PLUMBING (Updated) Yes No Yes No Yes No Yes No (If yes, year) (If yes, year) (If yes, year) (If yes, year)
Wiring Type	FUSES        CIRC. BREAKER
Plumbing Type	COPPER    PVC
Heating Type	Oil   Gas  Coal   Elec.
Central Air Conditioning?	Y N
# of Garage Doors	0 1 2 3 or More
Is Garage Attached (no house above)?	Y N
Is Garage Built In? (house above)?	Y N
Is There a Pool?	Y N
Is Pool Fenced-in?	Y N
Pool Type	Above Ground In-Ground

 

BASIC FIRE SAFETY PROTECTION INFORMATION
Distance from Fire Protection (Hydrant)	***SELECT*** Less Than 1000 Ft. Over 1000 Ft.
Distance from Fire Station	***SELECT*** Less Than 5 Miles More Than 5 Miles More Than 10 Miles
Is Your Area A "Brush" Area?	Y N
Smoke Alarm?	Y N
Smoke Detectors?	Y N    If Yes, how many
Fire Extinguishers?	Y N    if Yes, how many
Interior Automatic Fire Sprinklers?	PARTIAL FULL NONE
Fire Alarm	***SELECT*** Local Central Station None
Theft Alarm	***SELECT*** Local Central Station None
Deadbolts on All Doors?	Y N

 

REQUESTED COVERAGE
Coverage A  Dwelling - Replacement Value
Dwelling - Market Value
Coverage B  Other Structures Value
Coverage C  Personal Property / Contents
Coverage D  Loss of Use
DEDUCTIBLE	***SELECT*** $100 $250 $500 $1,000 $2,500 $5,000 $10,000 $20,000
Coverage E  Liability Limits Requested	***SELECT*** $100,000 $300,000 $500,000 $1,000,000 $2,000,000
Coverage F  Medical Payments to Others	***SELECT*** $1,000 $2,000 $5,000 $10,000
ADDITIONAL COVERAGE REQUEST
Water Backup Coverage	***SELECT*** $1,000 $2,000 $3,000 $4,000 $5,000 $10,000 $20,000
Off-Premises Theft Coverage?	Y N
Flood Coverage?	Y N
Is Flood Coverage Required?	Y N
Distance to Water
SCHEDULED ITEMS NOT INCLUDED IN BASIC Coverage (List Values) JEWLERY FURS ARTS COLLECTIBLES CAMERA EQUIP. SPORTING EQUIP. OTHER

CONTACT INFORMATION
First Name Last Name Email Phone                        Fax    Questions / Comments / Notes
Send my quotation via	E-Mail Fax Regular Mail Call me by Phone!
All quotes are based on the information that the applicant  provides, and are subject to change based on final underwriting by the  individual carriers.

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Privacy Policy-We routinely collect personal and/or business information that is needed as part of the quoting and underwriting process.  We also collect the same information as part of service and update activities.  The Haines & Haines/T.C. Irons Agency will not share that information, or use it in any other way, with outside parties, vendors, etc.

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