Phillip R Davis & Associates

Physical address:
Phillip R Davis & Assoc Inc.
1623 W Centre Ave
Portage Mi. 49024

Mailing address:
Phillip R Davis & Assoc Inc.
P.O. Box 1836
Portage Mi. 49081-1836

Agency: 269.327.1622

Toll Free: 800.642.4431

Fax: 269.327.1673

prdavis@tds.net

Ashley Gibney

269.492.3156
Email Ashley

Melanie Littell

269.492.3157
Email Melanie

Nancy Nap

269.492.3158
Email Nancy

Michelle Clark

269.327.1622
Email Michelle

Homeowner's Insurance Quote Form

To help us supply you with the most accurate quote possible, please answer as many questions as you can with the most accurate information available to you. Information submitted will be held confidential and will be used for quote purposes only.

Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

Personal Information *Indicates a required field
*Full name:
*E-mail:
*Daytime phone:
Evening phone:
Fax:
How would you prefer to be contacted regarding your quote?			Phone Fax Mail Email
If you prefer to be contacted via phone, please let us know the best time to call.			AM PM
Address:
City:
State:
*Zip:
County:
Township:
Occupation:
Date of birth:	mm/dd/yyyy
Employer:
Structural Information
What is the style of your home?					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?					1 story 1 1/2 stories 2 stories 2 1/2 stories 3 stories 4 or more stories Bi-Level Tri-Level
What is the total square footage of the living area of your home (excluding basement)?					sq. ft.
Select the structure of the following:
Roof:		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 home:		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:		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:		Brick Ceramic Tile Cork Grass Cloth Knotty Pine Mirror Paint Paneling Stone Wallpaper Other
Most flooring consists of:		Carpet over Hardwood Ceramic Tile Flagstone Hardwood Parquet Slate Wall-to-Wall Carpet Other
Garage:		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:		1 2 3 or more			Custom?			Yes No
Half bathrooms:		1 2 3 or more			Custom?			Yes No
Fireplaces:		0 1 2 3 or more
Decks:		0 1 2 3 or more			Total size:		sq. ft.
Enclosed porches:		0 1 2 3 or more			Total size:		sq. ft.
Open porches:		1 2 3 or more			Total size:		sq. ft.
Do you have any of the following in your home?
Swimming pool:		Yes No			Diving board:			Yes No
Trampoline:		Yes No
Burglar alarm:		None Local Central Police Station
Sprinkler system:		None Some rooms All rooms
Kerosene, wood, oil, or pellet stove:		Yes No
Dog:		Yes No			Bite history:	Yes No
					Breed:
Computer:		Yes No
Livestock:		Yes No
Unusual/Exotic pets:		Yes No
Is your home located:
Within 1000 ft. of a fire hydrant?		Yes No
Within 5 miles of a firestation?		Yes No
On a hillside?		Yes No
Close to a body of water or susceptible to flooding?		Yes No
General Questions
Year home was built:
Number of families living in the home:		0 1 2 3 4 or more
What part of the year is the home occupied?		Year round Seasonal (or Snowbird) Occasional Vacation None (Vacant)
Heating and cooling system:
What term best describes your kitchen?		Economy Standard Custom Designer
Is business conducted on the premises?		Yes No
Does anyone in the home smoke?		Yes No
Is the roof updated?		Yes No			Year:
Is the electrical updated?		Yes No			Year:
Is the heat updated?		Yes No			Year:
Is the plumbing updated?		Yes No			Year:
Did you experience any loss or claims in the last 5 years?		Yes No
If "Yes," please give dates, details, & amount paid:
Protective Devices
Smoke detectors?		Yes No
Fire extinguishers?		Yes No
Fire alarm?		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):						30,000 35,100 40,250 45,250 50,400 55,500
Personal property/contents (Coverage C - Typically 50% of Coverage A):						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):						60,000 80,000 100,000 120,000 140,000 160,000 180,000
Personal liability:						1,000 2,000 3,000 4,000 5,000 7,500 10,000 25,000
Medical payments:						1,000 2,000 3,000 4,000 5,000 7,500 10,000 25,000
Desired deductible:						250 500 1,000 2,500 5,000
Additional Data
Quote requested within:						24 hours 48 hours 72 hours 120 hours
Would you like an umbrella quote?						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 the 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 take valuables such as watches, jewelry, or furs with you?						Yes No
Do you buy items 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/sump pump coverage?						Yes No

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