Date Present Policy Expires:
Name:
Email: (required)
Home Phone:	Best Time to Call:
Business Phone:	Best Time to Call:
Address:
City:
Zip Code:
Property to be insured if different from above:
Address:
City:
Zip Code:
Property is:
Owner Occupied Tenant Occupied
Residence type is:
Single Dwelling Condominium Apartment	Mobile Home Other
Construction is:
Frame Frame Stucco	Brick or Stone Other
What is the approximate square footage of the home?
Number of Stories 1 1.5 2 3+
Number of Baths 1 1.5 2 2.5 3 3.5 4+
Size of Garage 1 car 2 car 3 car 4+ car
Type of Roof:
Wood Shake Tile	Asphalt/Fiberglass/Comp Shingles Other
Rating Information:
Year Home Built
Date Purchased	Purchase Price
Do you have smoke alarms? yes no
Do you have a burglary system? yes no
If you have a burglary system, is it monitored? yes no
Do you have dead bolts? yes no
Do you have fire extinguishers? yes no
Owner:
Date of Birth	Occupation
Joint Owner:
Date of Birth	Occupation
Do any residents in the household smoke? yes no
Have you had any homeowner claims or losses in the last three years? yes no
If yes, please indicate date, type of loss, and amount of claim
Existing or Desired Coverage:
Dwelling	$
Other Structures	$
Personal Property	$
Loss Of Use	$
Personal Liability	$
Medical Payments	$
Deductible	$
All quotes are based on replacement cost for dwelling and contents.
Do you want an earthquake coverage quote? yes no
Do you want a flood coverage quote? yes no
Once you have filled in the entire form click on the send button, and your information will be sent to TKB Insurance and Financial Services. There is no cost or obligation.