D.S.G. Douglas S. Gordon Insurance Services | Residential -Request a Quote

F.A.Q.

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Homeowners Quote Request Form
Please provide the following information and one of
our representatives will be in touch with you shortly.


Home Owners Information Only
Physical Address of Dwelling
Address:
City:	State:	Zip:


Coverage amount or limit of liability requested
Policy_Deductible:
Coverage A: Dwelling Replacement Cost:
Coverage B: Other Structrures Replacement: Typically limit is 10% of coverage A
Coverage C: Contents or Personal Property: Typically limit is 50% of coverage A
Coverage D: Additional Living Expenses: Typically limit is 20% of coverage A
Personal Liability:
Medical Payments:
Construction Type:
Year Built:
How may miles to the nearest fire department?
Is the dwelling located within 1,000 feet of a fire hydrant? :		Yes No

Discount Information This portion of the form is optional. However, if you qualify for these credits the savings can be substantail.
Have you had any claims in the last 3 years?		Yes No
If yes, please explain:
Do you have the following?
Fire Extinguisher		Yes No
Smoke Detectors		Yes No
Deadbolt Locks		Yes No
Fire Alarms
Burglar Alarm
Tile Roof		Yes No
Other Discounts
Are you 40 years or older?		Yes No
Are you retired?		Yes No
Gated/Secured Community?		Yes No
Have you been employed for 3 or more years?		Yes No

Mortgage Information
Mortgage Company Name:
Mortgage Company Address:
City:	State:	Zipcode:
Loan Number:

Do you own or rent?
What is the expiration date of your current Homeowners Insurance Policy?
Do you currently have homeowners insurance?	Yes No
Is any business conducted within this home?	Yes No

Has any coverage been declined, cancelled or not-renewed during the last 3 years?

Yes No