Contact Dorsey & Associates | Insurance Agency

Pre-Application for Homeowners’ Insurance

Owner’s Name:

Owner’s Date of Birth:

Marital status (single, married, divorced, widowed):

Owner’s SSN#

Co-Owner’s Name:

Co-Date of Birth:

Co-Owner’s marital status (single, married, divorced, widowed):

Co-Owner’s SSN#

Free Text

Purchase Address:

Current Address:

Phone:

Alternate Phone:

Email address:

How much is the property currently insured for?

Current insurance company:

Dwelling type (row, single, twin, ranch):

Is this a new purchase:

What is the annual insurance premium suggested by the mortgagee:

Settlement Date:

Residence type: (primary, secondary, rental)

Porch: (open/closed)

Year built:

Any sky lights (which room):

Heating: radiator (forced-air of radiator

Any fireplaces:

Design:

Alarm:

Roof: (roof material/design: ex: flat or a-framed)

Exterior wall:

Roof age:

Number of bathrooms:

Foundations: (poured/cement bricks/cement slabs)

Any other customizations:

Garage: (attached/detached) (1 car, 2 cars, 3 or more Cars)

6641 Germantown Ave.

Philadelphia, PA 19119

Phone: 215-713-2886 | Fax: 866-713-1173