Maine or New Hampshire Homeowners Insurance Quote Comparison Form*
Please check the Chalmers Group location nearest you, after you have completed and submitted this information we will contact you.
Maine Offices: Chalmers Insurance Agency, Bridgton, ME CE Carll Agency, Gorham, ME CE Carll Agency, Standish, ME Lovejoy & Wadsworth Agency, Parsonsfield, ME Pike Insurance Agency, Fryeburg, ME
New Hampshire Offices: Ossipee Insurance Agency, Center Ossipee, NH Palmer & Pike Conway Dahl, North Conway, NH
BASIC INFORMATION Please answer to following 20 questions and submit.
5. Information Disclosure in order to provide a competitive and accurate quote we may order consumer reports, including, but not limited to: credit scores, insurance scores, claims reports and driving records. I have read the disclosure and would like to continue: Yes No
DWELLING INFORMATION
6. Home Type: Owner Renter
7. Construction Type: Condo Frame Log Mobile home Modular home Other:
8. Is this a single family home? Yes No If no, number of families
10. Features (please check all that apply): Business conducted on property Storage of business property on premises Home office Home is rented to others Please explain any business: Deadbolts Smoke detectors Fire extinguisher Low temperature alarm Central fire alarm Sprinklers Central burglar alarm No smokers in household Home is within 1000 feet of hydrant Home is on an island Home is within 5 miles of fire station Home is within 2 miles of coast Swimming pool Tree house Home is under construction Trampoline Home is for sale Home is under renovation Homeowners's policy concelled within last 5 years (if checked, please explain): Claim within the last 5 years (if so please explain): Bankruptcy (if so please explain): Pets or animals on premises; if so please list all animals including number of animals, kind or animal and breed:
11. Type of heat (check all that apply) Oil - central Narual Gas - central Electric - central Liquid Propane - central Woodstove or Pellet Stove Monitor type - central Monitor type - space heater Fireplace If other, please indicate heat type:
12. Please indicate year the following was updated (if different than year built) Roof replaced: Heating system updated: Plumbing updated: Wiring & electric updated: and Is wiring circuit breakers? Yes No
13. Number of stories (not including basement): 1 1.5 2 2.5 Other:
14. Foundation: Crawl space Piers Slab Basement Finished basement
15. Square footage or dimensions of ground floor:
COVERAGES**
16. Replacement value of your home: $ **We will quote your homeowner's package with contents, loss of uses, other structures coverage and a $500 deductible; also $500,000 Personal Liability and $5,000 Medical Payments.
17. Name of current insurance company for this propery: Expiration or renewal date:
19. Optional Coverages (select any that you would like quoted): Earthquake Water Backup Law & Ordinance Flood Personal Umbrella
20. Other comments:
*This is for quoting purposes only. No coverage can be bound or changed using this system. Completion of this form does not provide coverage. There is no coverage until you have paid the premium deposit and signed the application.
