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Download Homeowner`s Information Request - Bloomfield Hills Insurance
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21 East Long Lake #100 Bloomfield Hills MI 48304 248-283-0250 X-200 800-775-3571 Fax 248-283-0251 [email protected] Homeowners Information Insured: Mailing Address: City: ________________________ State ___________________ Zip Code Email Address: _____________________________ Telephone No: Location Address: City: ________________________ State ___________________ Zip Code Coverages: Liability Limit __________________ Replacement Cost of Home Contents _______________________ Deductible: $1,000 $500 $250 Other Attach Jewelry, Fur and Fine Art Schedules. Location Information: Construction: Frame, Brick Veneer, Block or Brick Use: Primary Resident Secondary Garage: Attached/Detached Basement: Finished/Unfinished Square Footage Seasonal or Cottage Number of Cars _______ Sump Pump Y N Fire Hydrant within 1,000 feet: Y N Year Built Number of Baths Number of Fireplaces Distance to Fire Department Current Insurance Carrier ___________________________ Expiration Date Claims in the last 3 years Credit (circle all that apply) Central Alarm Local Alarm No Loss Payable Annual Payment Mature Homeowner – DOB ____________ Smoke Detectors / Deadbolts / Fire Extinguisher Multi Policy (Home + Auto) Insurance Credit Score – SSN 21 East Long Lake #100 Bloomfield Hills MI 48304 248-283-0250 X-200 800-775-3571 Fax 248-283-0251 [email protected] Year of Updates Construction Fireplace ______ Roof ________Heating _______Electrical Colonial ____ Ranch ____ Contemporary ____ Single/Double Roof Material Deck _______Plumbing Gas Natural Asphalt Shingle ______ yes ____ no _____ Pre-Fabricated size _____ Drywall % ______ Wall Coverings Paint % ____ Floor Covering Other % _____ Carpet % ____ Hardwood % ____ Plaster% ______ Wallpaper % ____ Builders Grade ______ Bathrooms # of ______ Woodburning Stove Rubber ______ Tile ______ Wall Partitions Kitchens Bungalow ____ Mural % _____ Panel % ____ Marble % ____ Ceramic % ____ Semi-Custom ______ Builder’s Grade ______ Drywall/Textures % _____ Custom _______ (Granite/Builtins) Semi Custom _____ Custom _______ French Doors ____ Wet Bar ____ Hot Tub/Jacuzzi _____ Elevator _____ Spiral Stairs ______ Heating System Forced Air ___ Hot/Water ___ Air Conditioning Yes ___ No ___ Fuel Source Radiator ___ / Using existing heat ducts ____ Separate ducts ____ Electric ___ Fuel Oil ___ Natural Gas ___ LPG ___ Furnace Age _____ Plumbing System Electrical Wiring Copper PVC # of AMPS _____ Galvanized Cast Iron Age _____ Circuit Breakers _____ Fuses _____ Romex _____ Conduit _____ BX _____ Knob/Tube _____ Swimming Pool Trampoline Yes ___ No ___ Yes ____ No ____ Inground Y/N ____ Above Y/N _____ Locked/Gated Screened Y/N _____ Name of Responding Fire Department __________________________________________ Additional Comments/Features _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
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