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Home Policy Protection Checklist


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Personal Information
First Name
Required
Last Name
Required
Street
Required
City
Required
State
Required
ZIP / Postal Code
Required
Primary Phone Number
Required
E-Mail Address
Required
Have you remodeled your home, added any additions, built any outbuilding or garages, or made any improvements to finish your basement?
Required

Would it cost more to rebuild your home, than the amount you have it insured for?
Required

Have you updated the wiring, heating, roof or plumbing in your home?
Required

If Yes, please give details:
Optional
Would you like to SAVE Money by increasing this deductible???
Required

If Yes, please check the deductible(s) you would like quoted:
Optional



Have you acquired any valuable guns, jewelry or collectable items?
Required

Have you added a new security or fire alarm system to your home? (If so please provide us with the installation certificate to receive a discount.)
Optional

Are you running any business out of your home or do you give private lessons on your premises?
Required

Are you babysitting two or more children in your home on a regular basis?
Required

Do you own any ATVs, boats, snowmobiles, or other recreational vehicles?
Required

If Yes, please give details:
Optional
Do you have a trampoline?
Required

Do you have any pets?
Required

If yes, please list the type of pet, breed and how many?
Optional
Do you have any rental or investment properties?
Required

Do you own a second home such as a weekend or summer property?
Required

Have you refinanced or changed your mortgage company this year?
Required

If Yes, please provide the mortgage company’s name, address, loan number, and phone number?
Optional
Would you like to have Flood coverage – annual price begins at $320?
Required

Would you like to have Earthquake coverage– annual price begins at $120?
Required

Would you like more information about purchasing Identity Theft Protection?
Required

Would you like to have your premium spread over 12 months and drafted from your checking account in order to have NO SERVICE FEES?
Required

Would you like a FREE No Obligation Review of your families Life Insurance Needs?
Required

Would you be interested in obtaining information on a $1,000,000 Umbrella Liability Insurance policy that would protect you in the event of a catastrophic accident for as little as $150 per year?
Required

Submission Validation
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

 
  107 N Main St. PO Box 2198 | Davidson, NC 28036
Ph: (704) 895-1075 | Fx: (704) 895-1074
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(704) 895-1075


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