PERSONAL INFORMATION First Name: Last Name: E-mail address: Daytime Phone Number: Evening Phone Number: Fax Number: How would you prefer to be contacted  regarding your quote? Phone   Fax   Mail   E-mail If you would prefer to be contacted by phone,  please let us know the best time to call. AM PM Address: City: State: Zip code: Social security number: Occupation: Date of birth: Employer: STRUCTURAL INFORMATION What is the style of your home? Select... Adobe Bungalow Cape Cod Colonial Contemporary Duplex Log Home Mediterranean Queen Anne Raised Ranch (Bi-Level) Ranch Split Level Timber Frame Traditional Tri-Level Victorian Other How many stories is your home? Select... 1 Story 1 1/2 Stories 2 Stories 2 1/2 Stories 3 stories 4 or more stories Bi-level Tri-Level How many rooms do you have? Select... 1 2 3 4 5 6 7 8 9 or more What is the total square footage of the living  area of your home? WHAT IS THE STRUCTURE OF THE FOLLOWING Roof: Select... Architectural Shingles Asphalt Shingle Built Up - Tar & Gravel Clay Tile Concrete Tile Corrugated Steel Fiber Shingles Mineral Fiber Shakes Mission Tile Rock Roof Roll Roofing Rubber Roof Slate Tin Wood Wood Shake Exterior of your home: Select... Adobe Aluminum Siding Asphalt Brick Veneer Brick Solid Cement Fiber Clapboard Concrete Block Concrete-Precast Logs Log Siding Mineral Fiber Painted Masonry Slump Block Split Block Stone-Precast Stone-Solid Stone-Veneer Stucco-On-Frame Stucco-On-Masonry Wood Shakes Wood Siding Other Foundation: Select... Slab on Grade Crawl Space Piers/Pilings/Stilts Unfinished Basement 25% finished basement 50% finished basement 75% finished basement 100% finished basement Walkout basement Wood foundation basement Most of the inside walls consist of: Select... Brick Ceramic Tile Cork Grass Cloth Knotty Pine Mirror Paint Paneling Stone Wallpaper Other Most flooring consists of: Select... Carpet over Hardwood Ceramic Tile Flagstone Hardwood Parquet Slate Wall to Wall Carpet Other Garage: Select... None Attached - 1 car Attached - 2 car Attached - 3 car Basement - 1 Car Basement - 2 Car Basement - 3 Car Built-in - 1 car Built-in - 2 car Built-in - 3 car Carport - 1 car Carport - 2 car Carport - 3 car Carport w/storage - 1 car Carport w/storage - 2 car Detached - 1 car Detached - 2 car Detached - 3 car What is the replacement cost of your home: HOW MANY OF THE FOLLOWING DO YOU HAVE IN YOUR HOME Full bathrooms: Select... None 1 2 3 or more Half bathrooms: Select... None 1 2 3 or more Fireplaces: Select... None 1 2 3 or more Decks: Select... None 1 2 3 or more Enclosed porches: Select... None 1 2 3 or more Open porches: Select... None 1 2 3 or more DO YOU HAVE THE FOLLOWING IN YOUR HOME Swimming pool? Yes No Trampoline? Yes No Burglar alarm? Select... None Local Central Police station Sprinkler system? Select... None Some rooms All rooms Kerosene, wood or oil stove? Yes No Dog? Yes No Computer? Yes No Livestock? Yes No Unusual/exotic pets? Yes No IS YOUR HOME LOCATED Within 1000 feet from a fire hydrant? Yes No Within 5 miles from the firestation? Yes No On a hillside? Yes No Close to a body of water or susceptible to flooding? Yes No GENERAL QUESTIONS Year home built: Number of families living in the home: Select... 0 1 2 3 4 or more What part of the year is the home occupied? Select... Year round Seasonal (or Snowbird) Occasional Vacation None (Vacant) Heating and cooling system: What term best describes your kitchen? Select... Economy Standard Custom Designer Is business conducted on the premises? Yes No Does anyone in your home smoke? Yes No Did you experience any loss or claims in the last 5 years? Yes No PROTECTIVE DEVICES Smoke detectors? Yes No Fire extinguishers? Yes No Fire alarm? Select... Local Central Fire station Deadbolt locks? Yes No ADDITIONAL INFORMATION Gated community with a security guard: Yes No Neighborhood watch program: Yes No Senior citizen discount (all occupants age 55 or above): Yes No HOMEOWNERS COVERAGES AND DEDUCTIBLES Dwelling (Coverage A - Replacement cost of your home): $ Other structure (Coverage B - Typically 10% of coverage A): $ Select... 30,000 35,100 40,250 45,250 50,400 55,500 Personal property/contents (Coverage C - Typically 50% of coverage A): $ Select... 150,000 165,000 180,000 195,000 210,000 225,000 240,000 Loss of use of your home (Coverage D - Typically 20% of coverage A): $ Select... 60,000 80,000 100,000 120,000 140,000 160,000 180,000 Personal liability: $ Select... 100,000 300,000 500,000 Medical payments: $ Select... 1,000 2,000 3,000 4,000 5,000 7,500 10,000 25,000 Desired deductible: $ Select... 250 500 1,000 2,500 5,000 ADDITIONAL DATA Quote requested within: 24 hrs  48 hrs  72 hrs   120 hrs Do you want an umbrella quote: Select... Yes No I don't know OPTIONAL QUESTIONS If you have a collection that is anything of value such as Coins, Stamps, Art etc., specify the value of your collection: $ If you have any furs or jewelry, please specify the approximate value/limits: $ Do you have any special interests or hobbies that could be  considered a home based business? Yes No Do you travel? Yes No Do you travel outside of the United States? Yes No When you travel, do you bring valuables such as watches, jewelry, or furs with you? Yes No Do you buy things while traveling and want to know that they are immediately insured under your policy? Yes No If your home were destroyed, would you want to rebuild it in the same location? Yes No Do you have/want backup of sewers and drain coverage? Yes No
	To speak with one of our agents, please call us at ( (603) 262-3300 or toll free at (800) 698-2750 Monday - Friday between 8:30 am and 5:00 pm. For your convenience, you may also reach us by Fax at (603) 262-3444 customerservice@abinh.com