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South Milwaukee:
(414) 762-8900
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Get a Home Quote
Name
*
Email
*
Phone (optional)
Address
City/Zip Code
County
Section Break
Date of Birth
Current Occupations
Life Insurance
Present Company
Expiration Date
Year house purchased
Do you have a Mortgage?
Yes
No
Mortgage Pay Insurance?
Yes
No
Any losses in last 5 years (please describe)
REPLACEMENT COST INFO
Construction Year
# of Families
# of Stories
Square Footage
Type of Construction
# of Baths
Garage Type
(heat in garage)
Finished Basement
Fireplace
Gas
Wood
None
Central Air
Yes
No
Alarm System
Yes
No
Wood Deck
Porch
Balcony
Coverage
Coverage A: Current Dwelling $
RC est $
Purchase Price (if new)$
Deductible
MED PAY
PRIOR LIABILITY LIMITS $
Updates to the Home
Roof Year
Type of Shingle
Composite
Architectural
Other
Type of Central Heating
Furnace
Boiler
Other
Year installed
Year inspected
Plumbing Year
Wiring Year
Circuit Breakers
Yes
No
Do you have galvanized plumbing (homes built in the 1960s or prior)
Distance to the Fire Dept (miles)
Distance to Fire Hydrant (ft)
Underwriting Questions
Do you have a trampoline?
Yes
No
Do you have a Fenced Yard?
Yes
No
Swimming Pool Questions
Swimming Pool
None
Above Ground
In Ground
Inflatable or temporary
Is the pool or yard fenced (if so, describe)
AAA, ACUITY, IMT, and MET LIFE require a fence no matter what.
Above ground–4’(city ord.)
Deck around pool
Locked gate/Removable ladder Diving Board or slide
Type of diving board (one meter or flush)
Pool depth under slide
Pool depth under diving board
Wood Burning Stove
Stove/Fireplace
Wood Burning
Pellet Burning Stove
Fireplace insert
Year/Make of the stove
# of days per week used
Type of floor under stove
Where in the home is the stove installed
Who installed stove?
Are they licensed?
How often is the stove cleaned?
When was the stove last cleaned?
Pets
Types
Do you have any of these breeds?
Yes
No
Akita – American Bulldogs – Beaucerons – Belgian Malinois – Caucasian mountain dogs – chow chow – Doberman pinchers – German Shepard – Great Danes – Keeshonds – Mastiffs – pit bulls – Rhodesian ridgebacks – Rottweilers – Staffordshire terr
Any bites
How old
How long owned
Gender
Are they fixed?
Obedience Training and when?
Height/weight
Is the dog mostly inside or outside?
If outside is it kept chained?
If outside is it kept chained?
If so, front yard or back yard
Is the yard fenced in?
Children in the house or neighborhood?
Do you have a “Beware of Dog” or “Dog on Premises” sign posted, where?
MISC
Water Backup/Sump Pump coverage?
Any Jewelry, Watches, furs scheduled?
Home Day Care / Farming / B & B / Home Business
Does anyone smoke?
Yes
No
Anyone under 21 years old?
Yes
No
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