Personal Home Owners & Renters Insurance from Haines & Haines TC Irons Insurance

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.

Homeowners & Renters Insurance Quotation

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

# 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

    Other (Type of Residence)

Construction Type

    Other (Construction Type)

Roof Type

    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)

Distance from Fire Station

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

Theft Alarm

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

Coverage E Liability Limits Requested

Coverage F Medical Payments to Others

ADDITIONAL COVERAGE REQUEST

Water Backup Coverage

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.

Our Mission Statement

Dating back from 1872 our mission is clear:

To serve our clients with the utmost respect, integrity and professionalism while providing a comprehensive risk management program at competitive pricing

Policy Coverage
and Disclaimer

Contact

	Haines & Haines/ T.C. Irons
16 West Front Street Florence, NJ 08518 Phone: 609.499.0237 Fax: 609.499.4077	230 High Street PO Box 158- Burlington, NJ 08016 Phone: 609.387.0606 Fax: 609.387.5337	1-3 Bank Street Suite E Medford, NJ 08055 Phone: 609-953-2282 Fax: 609.953.7719
	Wesley Insurance Service Agency 1194 Parkway Avenue Trenton, NJ 08628 Phone: 609.883.4190 Fax: 609.538.0274