| Fields marked (*) are mandatory. |
| NAME, ADDRESS AND CONTACT INFORMATION |
First Name*
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Last Name:* |
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| Address 1 * |
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City *
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| State * |
VA |
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| Zip Code * |
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| County |
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| Home Phone: |
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| Work Phone:* |
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| E-mail* |
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| Number of years resided at property address: |
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| If you have resided at your current address for less than 3 years, please list your previous address |
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| PRIOR INSURANCE |
| Do you currently have homeowner's insurance? |
Yes
No |
| Current Insurance Company |
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| Renewal Date |
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| Are you currently in the process of purchasing a home? |
Yes
No |
| Estimated Closing Date |
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| PROPERTY GENERAL |
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| Distance to Fire Station |
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| Distance to Hydrant(ft) |
Under 1000
Over 1000 |
| Year Built * |
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| Property Use |
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| Square Footage * |
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| House built on |
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| If the house is built on a basement, is the basement finished? |
Yes
No |
| Garage |
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| Swimming Pool? |
Yes
No |
| Number of Families |
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| Number of Stories |
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| Dog Type |
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| CONSTRUCTION DETAILS |
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| Construction Type |
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| Roofing Material |
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| Age of Roof |
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| Electrical Type |
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| Heat Type |
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| Does the home have a free-standing woodstove? |
Yes
No
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| Number of Fireplaces |
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| Number of Full Bathrooms |
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| Number of Half Bathrooms |
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| PROTECTION DEVICES |
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| Smoke Detector? |
Yes
No |
| Central Burglar / Fire Alarm? |
Yes
No |
| Fire Extinguisher? |
Yes
No |
| Does Building have a Sprinkler System? |
Yes
No |
| Does Building have a Dead-Bolt Locks? |
Yes
No
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APPLICANT INFORMATION |
| Date of Birth* |
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| Marital Status |
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| SSN # optional, but helpful for an accurate quote |
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| Rate your credit |
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| CO-APPLICANT(SPOUSE) INFORMATION |
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| Relationship to Applicant |
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| First Name |
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| Last Name |
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| Date of Birth |
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| SSN # optional, but helpful for an accurate quote |
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ADDITIONAL INFORMATION
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The questions bellow will help the Insurers to determine the best discounts to be awarded |
| Have you reported losses during the past 5 years? |
Yes
No |
| Any business conducted on premises? (including day/child care) |
Yes
No |
| BASIC COVERAGES |
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| Personal Liability |
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| All Perils Deductible |
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By submitting this information, I understand that Virginia Insurance Group may contact me via e-mail, phone or fax, using the information I have supplied, to provide quotes or to obtain additional information needed to provide quotes.
Where permitted by law, some insurance companies may confirm your information, through the use of reports which may include driving record and credit score. |