New Hampshire Homeowners Quote Request

Brownell Insurance Center, Inc - Derry NH - Your NH Auto and Homeowners Specialists

New Hampshire Homeowners Insurance Quote

Please complete the following form and one of our agents will contact you promptly to discuss coverages and pricing for your particular needs.

*This form is for information only and does not afford any coverage. Coverage must be submitted or bound by one of our authorized insurance agents and initial premium paid before any insurance is in force.

Personal Information

First Name:
Last Name:
Address:
City:
State:	Zipcode:
Home Phone:
Work Phone:
Fax Number:
Where to Contact:	When to Contact: AM PM
Email Address:
Birth Date (mm/dd/yyyy):	(for discount purposes)
How would you rate your credit?
Property Information
Address:
City:
State:	Zipcode:
What is your mortgage balance?
What is the market value of your home?
Number of Families:
What is the dwelling type?
Number of bedrooms:
Number of Full bathrooms:	Number of Half bathrooms:
Number of Fireplaces:
Number of porches or decks:	Square Footage of Porch/Deck
Year dwelling was built:	Date purchased: (mm/dd/yyyy)
What is the construction type?
How many stories?
If two or more stories, what is the ground floor sq. footage?
What is the total building square footage?
What is the property's topography?
Foundation Type:
If in flood zone - what is the distance to body of water?
What type of garage?
What type of roof covering?
Was the roof updated?	Yes No If yes, what year?
Does the building have a pool?	Yes No
If there is a pool, is it fenced in?	Yes No
If there is a pool, is the fenced lockable?	Yes No
If there is a pool, is there a diving board?	Yes No
If there is a pool, is there a slide?	Yes No
Distance to Fire Department:	(miles, ie. 0.5, 1.0)
Distance to Fire Hydrant:	(feet)
Is the building in the brush?	Yes No
Is there a brush hazard within 1 mile of building?	Yes No
Is there a smoke alarm?	Yes No
Is there a fire extinguisher?	Yes No
Are there deadbolts?	Yes No
Is the electrical updated?	Yes No
Are there circuit breakers or fuses?
Does the electrical box have copper wiring?	Yes No
Is there central air conditioning?	Yes No
How old is the heating/air conditioning?
Is the heating/air conditioning thermostatically controlled?	Yes No
What is the energy source?
What is the heating system?
What is the cooling system?
Has the plumbing been updated?	Yes No
Is the plumbing copper?	Yes No
Does the building have interior automatic fire sprinklers?	Yes No
Is there a theft alarm?	Yes No
Is there a fire alarm?	Yes No
Are the alarms monitored?	Yes No
What is the earthquake zone?
Has it been earthquake retrofitted?	Yes No
What is the fire district?
Do you have a trampoline?	Yes No
Number of acres dwelling is located on:
Are there dogs on the property?	Yes No
If so, how many and what is the breed of each dog?
Are there any other pets or animals on the property?	Yes No
If yes, how many and describe each:
Current Coverage Information
What is the current insurance company?
What is the expiration date of the current policy?	mm/dd/yyyy
Were there any losses or claims in the last 5 years?	Yes No
If yes, what is the date, amount paid and description of loss:
Desired Coverage Information
Dwelling Amount:
Other Structures:
Personal Property:
Loss of Use:
Premise Liability:
Policy Deductible:
If earthquake insurance is requested give deductible percentage:
Do you want building replacement cost coverage?	Yes No
Do you want contents replacement cost coverage?	Yes No
Questions or Comments:

Brownell Insurance Center, Inc. • 122 West Broadway, Derry, NH 03038
Phone: 603.437.1992 • Fax: 603.437.4846 • www.BrownellInsurance.com