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Press the "TAB" key to move between the fields of this form.
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Name
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Name of Employer |
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Home Phone
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Work Phone |
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Street Address
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Email Address |
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City
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State
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Zip Code
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How You Found Us
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If you found us by some other source not listed to left, please specify below |
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Name of Homeowner's Insurance Company (Please note that you may be eligible for savings if Pavese-McCormick provides your Auto Insurance)
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Enter Value of Losses Claimed in the Past 3 Years (Please type "0" if you have not claimed any losses in the past 3 years.) |
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Who is your home occupied by?
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# of families |
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Owner Tenant
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# of stories
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Year Built (Please use a four digit format, i.e., 1988, 2000) |
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Square Feet
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Exterior Wall Material |
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Construction Class
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Basement |
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Square feet |
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Garage
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Square Footage of Balcony or Deck |
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Is there a Swimming Pool on your property?
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Porch Definition |
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Yes No
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Square feet Enclosed |
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Fireplace/Chimney
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Do you have a hearth, if so how many stories? |
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InsideOutside
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YesNo Stories |
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Heating System Type
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Air Conditioning |
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# of Full Baths
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# of Half Baths |
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Please Enter Year Updates were Performed for the Following
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Roof Heat
Plumbing Electric
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Credit Eligibility - Please answer the following so that we may ascertain whether you are eligible for credits toward your Homeowner's Insurance
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Is the home a non-smoking environment?
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Yes No
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Is the home equipped with an alarm and/or protective device?
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Yes No
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Additional Comments:
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