HOMEOWNER'S NAME:
HOMEOWNER'S ADDRESS:
CITY & STATE:
ZIP CODE:
HOME PHONE:
WORK PHONE:
E-MAIL ADDRESS:
NAME of CO-OWNER/SPOUSE (if any):
As part of our underwriting process for all applicants, to provide you with an accurate premium amount, we must ask you a series of questions. Your answers to some of these questions will be confirmed through consumer reports, which may include credit information. This information will be available to all of the business entities that make up our Group of Insurance Companies. Do you wish to continue?
(Please indicate "YES" or "NO"):
Is owner a smoker? (YES/NO): Is co-owner a smoker? (YES/NO):
A. Birthdates and Social Security Numbers of Owners:
1. NAME:
Date of Birth:
Social Security Number:
2. NAME:
Date of Birth:
Social Security Number:
Year dwelling was built: Square Footage of Dwelling:
AGE OF ROOF:
ROOF TYPE (e.g., Asphalt/Shingle, Asphalt/Fiberglass-Hail Warranted, Asphalt/Fiberglass-300 lb, Slate, Concrete/Cement-Fiber Tile-6, Copper, Rock/Tar Gravel, Rolled Asphalt-Flat, Rolled Asphalt-Peaked, Sheel Metal Panel, Asphalt/Fiberglass or Dimensionless Asphalt, Spanish Tile, Steel Tile/Shingle, Synthetic Shingle/Tile, Wood Shingle/Shake):
POLICY TYPE (e.g., Homeowners, Condo/Townhome, Landlord Protector, Renters, Mobilehome-in-Park, Mobilehome-not-in-Park):
NUMBER OF UNITS: OUTSIDE OF CTY LIMITS? (Y/N):
TYPE of SIDING ON DWELLING (e.g., Adobe, Alum/Plaster/Vinyl over Frame, Asbestos Siding, Comp Roll Siding, Frame-with-0%-to-33%-Masonry-Veneer[BRICK], Frame-with-34%-to-66%-Masonry-Veneer[BRICK], Frame-with-67%-to-100%-Masonry-Veneer [BRICK], Log Home, Log-Home-with-Finished-Interior, Solid Masonry-Brick/Stone/Etc):
PROTECTIVE DEVICES:
Deadbolts on Exterior Doors? Smoke Detectors?:
Fire Extinguishers? Year Renovated?:
Central Alarm (monitored)? Local Burglar A. (sounds locally)?:
Sprinkler? Age of Heating?:
Age of Plumbing? Electric?:
STYLE CODE (e.g., Bi-Level/SRD Ranch, Geodesic Dome, Modular Home, Split Level, Townhome [Center Unit], Townhome [End Unit], Underground Dwelling, 1 Story, 1 1/2 Stories, 2 Stories):
GARAGE TYPE (e.g., Carport, Detached, 1-Car Attached, 1-Car Built-In, 2-Car Attached, 2-Car Built-In, 3-Car Attached, 3-Car Built-In, None):
Nearly finished! (Please continue on PAGE 2.)
PAGE 2
INTERIOR WALLS (e.g., Drywall/Sheetrock, Plaster):
KITCHEN TYPE (e.g., ECONOMY = 16' of Counter & Cabinets, Stainless Steel Sink, Stove; STANDARD = 24' of Counter & Cabinets, Rangehood,Garbage Disposal; CUSTOM = 30' of Cabinet Base, Ceramic Tile Counter & Splash, Wall Oven, Built-in Dishwasher, Trash Compactor, Pantry, Water Filter; LUXURY = 36' of Cabinet Base, Stone Slab Counter & Splash, 2 Sinks, Wall Micro-Wave, Indoor BBQ, Hot Water Dispenser, and Cooktop.):
BASEMENT:
Percentage of Ground Floor Percentage of Basement Finished
BATHROOM TYPES (e.g., STANDARD = 1 Toilet, 1 Sink, Ceramic Tile Counter Top, Wood Cabinets; CUSTOM = 2 Sinks, China Finish, Marble Counter Top, Separate Shower & Tub, and Spa; LUXURY = 2 Sinks, China Finish, Marble Counter Top, Separate Shower & Tub, Spa Tub, and Bidet.):
NUMBER OF FULL BATHS: NUMBER OF HALF BATHS:
NUMBER OF FIREPLACES: NUMBER OF STORIES:
NUMBER OF GARAGE-DOOR OPENERS:
BREEZEWAY (Y/N): PORCH, OPEN (Y/N): DECK (Y/N):
BREEZEWAY, OPEN (Y/N): PORCH, SCREENED (Y/N): SHOWER STALL (Y/N):
AIR CONDITIONER (Y/N): MARKET VALUE OF PROPERTY:
GREENHOUSES (Y/N): SCREENED POOL ENCLOSURE (Y/N): SOLAR PANELS (Y/N):
STAINED GLASS (Y/N): SAUNA (Y/N): SPIRAL STAIRCASE (Y/N):
ORNAMENTAL STAIRS (Y/N): ELECTRIC AIR CLEANER: CENTRAL VACUUM:
LAUNDRY TUB (Y/N): INDOOR BBQ: INTERCOM SYSTEM:
ADDITIONAL FURNACE: TRASH COMPACTOR:
SKYLIGHTS (Y/N): EXTERIOR SHUTTERS (Y/N): INTERIOR SHUTTERS (Y/N):
WET BAR (Y/N): JACUZZI (Y/N): ADDITIONAL ALLOWANCE (Y/N):
INCREASED LIABILITY EXPOSURE or UNUSUAL HAZARDS:
Swimming Pool (Y/N) If YES, is pool surrounded by 6' Fence? (Y/N) Trampoline (Y/N)
Any business-use of home? (Y/N) Kind of Business?:
Value ($$) of Business Property/Inventory? First-Responding Fire Department:
Distance to Fire Department in Miles CURRENT INSURANCE COMPANY, if any:
EXPIRATION DATE CURRENT PREMIUM:
How is current premium paid? (e.g., Mortgage company pays; OR, Insured pays.):
NUMBER OF CLAIMS FILED IN LAST 3 YEARS and AMOUNT PAID:
CURRENT INSURANCE COVERAGE $$ for Dwelling:
CURRENT INSURANCE COVERAGE $$ for Personal Property:
You may include any additional information here. Please feel free to include your comments.
THE ARVISOM INSTITUTE
FARMERS AGENT: Marvin C. Sterling
vinsterling@gmail.com
2200 Shadowlake Drive
Farmers Insurance Group
Oklahoma City, OK 73189-2165