Homeowner Insurance

Markus Insurance Agency

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Personal Information

(years) Age Deck?

First & Last Name *

Street Address *

Address Line 1

City

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Zip Code

Email *

Phone *

Date of Birth

Occupation

Home Information

Property to Insure *

• Same Address as Above
• Different Address than Above

Street Address *

Address Line 1

City

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Zip Code

Year Built

TypeBasic tractBasic tractCustomStandardUpgraded / remodeled

Stories1.5-story (split)1.5-story (split)1-story2-story

Living Space (sq ft)

ConstructionFrame or stuccoFrame or stuccoMasonryMasonry veneer

FoundationBasementBasementCrawl spaceSlab

Age of Electric (years)

Age of Plumbing (years)

Age of Heating (years)

Home Interior

Full Baths

Half Baths

Chimneys

Hearths

Finished Basement?

• Yes
• No

Basement Size (sq ft)

Central Air?

• Yes
• No

Security System?

• Yes
• No

Home Exterior

Garage TypeAttachedAttachedBasementBuilt-inCar portDetached

Garage SizeFour-carFour-carSingle-carThree-carTwo-car

Roof TypeAsphalt shingleAsphalt shingleTile or slateWood shingleOther

Roof Age (years)

Deck?

• Yes
• No

Deck Size (sq ft)

Screened-In Porch?

• Yes
• No

Porch Size

Pool?

• Yes
• No

Pool Fenced?

Coverage Information

Currently Insured?

• Yes
• No

Current Insurance Company

Current Insurance Policy Expiration

Current Policy Coverage ($)

# Claims in Past 5 Years

Additional Desired Coverage

• Appliance Breakdown
• Earthquake
• Flood
• Identity Theft
• Jewelry

Dog?

• Yes
• No

What Breed?

Anything Else?

Comments

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