Please print out and fax to 321.727.0952

Insurance Icon, Inc.

Homeowners Quote Worksheet

115 Hickory Street, Suite 206

Melbourne, FL 32904

Phone (321) 727-0951 Fax (321) 727-0952

Applicant’s Information

Name

Street Address

City, State, Zip

Previous Address If Less Than 3 Years

City, State, Zip

Marital Status

Date of Birth

Home Phone ( )

Work Phone ( )

Social Security #

Employer

Employer Street Address

Employer City, State, Zip

Occupation

Years with Employer

Do you own or rent? Own ____ Rent ____

Length at address

Does applicant have any foreclosures, repossessions, bankruptcies, judgements, or liens during the past five years? If yes, please explain __________________________________________________________________________ Yes No ___________________________________________________________

Does applicant own any recreational vehicles (dune buggies, mini bikes, ATV’s, etc)? List year, type, make, model _______________________________________________________ Yes No

During the last five years has the applicant been convicted of any degree of the crime of arson? If yes, please explain __________________________________________________________________________ Yes No ___________________________________________________________

Co-Applicant’s Information

Co-Applicant’s Name

Social Security #

Marital Status

Date of Birth

Occupation

Years with Employer

Co-Applicant’s Employer

Employer Street Address

Employer City, State, Zip

Property Information

Closing/Purchase Date

Mortgage Company

Mortgage Co. Phone # ( )

Purchase Price

Address- Location of property to be insured

City, State, Zip

Present Homeowner’s Insurance Company

Policy Expiration Date

Policy #

Current Premium

Year Built

Square Footage (Under Air)

Total Square Feet

Building Type Dwelling Condo Townhouse

Construction Type Masonry Frame

Roof Type Shingle: ___ Asphalt ___ Wood Tile : ___Concrete ___ Clay

Garage Yes No Square Feet __________ # of Cars ___ 1 ___ 2 ___ 3 ___ 4 Attached Built In Carport

Pool Yes No In-ground Above Ground Diving Board Screened Yes No Fenced In Yes No

Does any resident smoke? Yes No

Metal

Is there a porch/patio? Yes No Enclosed/Screened Yes No

How many stories/floors? ___ 1 ___ 2 ___ 3 Gated Community Yes No Security Guard Yes No

Burglar System Yes No Sprinkler System Yes No

Hurricane Shutters Yes No

Trampoline Yes No

# of Bedrooms ___ 1 ___ 2 ___ 3 ___ 4 ___ ______ # of Bathrooms ______ # of Half Baths ______

Updates done to Date Replaced Roof ______________ AC/Heat ______________ Electric ______________ Plumbing ______________

Fire Place Yes No Wood-burning Gas

Dwelling Foundation Concrete Slab Crawl Space

Miles To Fire Department

Responding Fire Department

Feet to Fire Hydrant

Animals Yes No Type _____________________________________ Breeds __________________________________ Bite History Yes No ________________________________________________________________________________________

Claims/Losses in Past 5 Years at this location or any other

Date

Description

Dollar amount

Date

Description

Dollar amount

Present Auto Insurance Company

Present Life Insurance Company

How did you hear about us?