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HATFIELD INSURANCE AGENCY


Homeowner Quote Questionnaire
Name
Address
City
State
Zip
Phone:
Soc. Sec. #
Date of Birth
Occupation
Mortgage Balance
Do you own a home?
Do you own a condo?*
Do you rent?*
*If you answered yes to owning a condo or renting, call us directly at 203-256-5660

Home Information
Main residence
secondary residence
investment house
Construction
Age of House?
Square Footage?
Design
Have Basement?
Present Policy Limit?
Have Garage?
Have Pets?
Have Trampoline?
Type & Breed?
Have Pool?
Do you have an underground oil tank?
Do you have a central burglar alarm?
Do you have a central fire alarm?
How many feet to nearest hydrant?
Have you had any claims in the last 3 years?
If yes, please describe below:



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