Name: Procter Insurance Agency
Address: 2315 10th Avenue, South Milwaukee, WI, 53172, US
Telephone: (414) 762-8900

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Address
City/Zip Code
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Section Break
Date of Birth
Current Occupations
Life Insurance
Present Company
Expiration Date
Year house purchased
Do you have a Mortgage?
Mortgage Pay Insurance?
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
Central Air
Alarm System
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
Type of Central Heating
Year installed
Year inspected
Plumbing Year
Wiring Year
Circuit Breakers
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?
Do you have a Fenced Yard?
Swimming Pool Questions
Swimming Pool
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?
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?
Anyone under 21 years old?
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REPLACEMENT COST INFO

Coverage

Updates to the Home

Underwriting Questions

Pets

MISC

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