J Byrne Insurance Agency

"Homeowner's Insurance Questionnaire"

Homeowner's Insurance Questionnaire
Please take five minutes of your time to find how much you can save. It is understood that this is not an application for insurance. There is no obligation and no sales person will call or visit me.		J. Byrne Agency, Inc. 5200 New Jersey Ave., Wildwood, NJ 08260 Phone 609-522-3406 / Fax 609-522-2844 Website: www.jbyrneagency.com

NAMED INSURED INFORMATION (AS SHOWN ON DEED)
Last Name:	First Name:		Today's Date:
Social Security Number:		DOB:
Social Security Number:		DOB:
Mailing Address:		Apt/Unit #:
City:	State:		Zip:
Property Address:		Apt/Unit #:
City:	State:		Zip:
Are the customers non-smokers?
Is this a waterfront property?		Is this property built over water?
Is this a condo unit?		Is coverage needed for a closing?
If condo what floor?		If condo how many units?
Name of condo association:
Home Phone:	Work Phone / ext:		Cell Phone:
Fax:		E-mail Address:

PROPERTY INFORMATION
Purchase Date:	Mortgage Amt:		Number of Stories:
Roof Type:	Square Footage:		Number of Families:
Heat Type:	Construction:		Year Built:
UPDATING DATES
Roof:	Plumbing:
Wiring:	Heating:
Is there a pool?		Are there any animals on property?
Describe animals and bite history:
Is there a business on premises?		Is there a trampoline on premises?
Has there ever been an underground oil tank?		Foreclosures or bankruptcies?
Is the home under construction or renovations?		Are fire hydrants within 2 blocks?
Number of buildings on property:		Garage or Shed:
Is there a basement?		Is there a crawl space?
Occupancy:
Protective Devices:
Claims in last 5 years:

COVERAGES DESIRED
PROPERTY COVERAGE
Dwelling Limit:			Other structures:
Contents Limit:			Liability:
Any Scheduled Items:
FLOOD COVERAGE (If desired) - If built after 1975, an FEC is required in order to quote
Dwelling Limit:			Contents Limit:
Describe Garage:			Items in Garage:

MISCELLANEOUS INFORMATION
Current Carrier:		Dwelling Coverage:
Referred to us by:		Expiration Date:
Mortgagee Name / Address
Continued:
Reason for leaving current carrier:

WHO COMPLETED THIS FORM?
Full Name:		Today's Date:

FAIR CREDIT STATEMENT
Note: You must agree to the following terms in order to use this service. Please read the statement below, carefully - before proceeding.
I understand that the J. Byrne Agency, Inc. on behalf of the Insurance Company will order an investigative consumer report as part of the underwriting process to qualify, evaluate, and quote my insurance coverage. Various consumer reports such as motor vehicle reports, credit reports, and claim history with prior insurance companies, may be obtained. In the event that the coverage is denied based on information in one of these reports, I will be advised of this and given the name and address of the consumer agency making the report. Please note: The price estimate (or quote for insurance coverage) provided to you by the J. Byrne Agency, Inc. will be base on the information supplied by you on this application. I Have Read the "Fair Credit Statement - and I AGREE to the terms set forth. WARNING: Do NOT Continue without checking the box above. You will not be able to continue and the answers to the questions you just answered may be lost.

Wildwood, NJ
5200 New Jersey Avenue
PO Box 1409
Wildwood, NJ 08260
Phone (609) 522-3406
Fax (609) 522-2844

Marmora, NJ
200 Route 9 South, Unit 1
Marmora, NJ 08223
Phone (609) 390-5566
Fax (609) 390-5577

Cape May Court House, NJ
1032 Route 9 South
Cape May Court House, NJ 08210
Phone (609) 465-7710
Fax (609) 465-9346

Cape May , NJ
917 Madison Avenue
Cape May, NJ 08204
Phone (609) 884-3333