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HOMEOWNERS/Condo/Renters INSURANCE REQUEST

*The following quote request is a non-binding document. All properties must first be inspected by a qualified agent prior to initiating a policy.

To provide an accurate estimate, please complete the general questions below, and continue to the remaining required coverage questions. (This information will be made available to AAA's underwriting companies, and will be confirmed through consumer reports, which may include credit information.)

Are You a AAA Member? Yes No

Is your vehicle currently insured with AAA? Yes No

First name:*

Last name:*

Address:*

Apt#:

City:*

State: * Zip:*

Date of Birth:*

Day Time Phone: *

E-Mail Address: *

Is the above address the location of the property you wish to insure? Yes No

If No, please provide the location of the property you wish to insure:

Notice to members using e-mail filtering SPAM software

Is this home a new purchase? Yes No

Current Homeowner's Policy
Company Expiration Date:

Underwriting Questions

What type of home will you be insuring?

Style:

Total Living Area: sq. ft.

Have you had any property loss or liability claims in the past 3 years? Yes No

If yes, Please describe the details of the loss:

Have you had insurance coverage declined, cancelled or non-renewed during the last 3 years? Yes No

If yes, please explain:

Have you filed for Bankruptcy, had your home or business repossessed, or foreclosed within the last 5 yrs?
Yes No

Do you have a trampoline on your premises? Yes No

What type of swimming pool do you have (if applies)?
If you do have a swimming pool do you have the following?
Diving Board Slide

Do you own a dog? Yes No
If yes, what breed is your dog? (If mixed, please be specific)

How many feet is the house to the nearest fire hydrant?

How many miles is the house from the fire department?

Which of the following do you have in your home? Check all that apply

fire alarm fire extinguisher sprinklers
burglar alarm deadbolt locks smoke detectors

Part I Property Damage

If you are currently insured with another carrier, you can find a list of the Coverage's "A" through "F" on your current insurance company's coverage selections page.

Coverage A (Dwelling)

If you are unaware of your home's current replacement cost, please check the box below and a AAA insurance agent will contact you to establish an insurable value.

I am unaware of my home's insurable value. (Fill in known amounts of coverages A-F.)

Coverage B (Other Structures)

Coverage C (Personal Property)

Coverage D (Loss of use)

Part II Liability

Coverage E (Personal Liability)

Coverage F (Medical Payment)

Deductible

Final Underwriting Questions

Type of construction? Frame Masonry Aluminum

Is this your primary residence? Yes No

Type of heating? Central Yes No

Gas Oil Electric Wood Coal Solar

Circuit Breakers Yes No

Original year of construction

Do you have a wood stove? Yes No

Have your roof, electrical, plumbing and heating systems been updated within 20 years?
Yes No If yes, when?

If you would like a quote for any specific item that you currently have insured above and beyond your coverage C (personal property) limit, Please list the items below along with their itemized values and they will be included along with your quote. (I.E. Jewelry, fine art or silverware)

Where would you like to send your request?

Please select a AAA Branch Office
that you would like to have your information transmitted to:

Our Territory: AAA Pioneer Valley serves members in Franklin County,
Hampden County, and Hampshire County, Massachusetts.
Copyright 2007. AAA Pioneer Valley