The Affordable Insurance Network of Delaware

The Affordable Insurance Network Of Delaware

Personal Information
First Name:		Last Name:
Address 1:
Years Residing:
Address 2:
City:		State:	Zip:
Home Telephone:		E-mail Address:
Cell Phone:		Work Phone:

Home Owners Information Only
Previous Address (If you have been at the above address for less than 3 years)
Address:
More Address:
City:		State:		Zipcode:

Mortgage Information
Mortgage Company Name:
Mortgage Company Address:
City:		State:	Zipcode:
Loan Number:
Do you currently have homeowners insurance?		What is the expiration date of your current Homeowners Insurance Policy?
Do you own or rent

Coverage amount or limit of liability requested
Home		Other structures (detached garages for example )
Personal property or contents		Loss of use
Personal Liability Limit?		Medical Payments
Deductible for property coverages?
Construction Type:		Year Built?
Market Value:		Distance to nearest fire hydrant in feet:
Distance to nearest fire hall in miles:		Do you have smoke detectors?
Do you have burglar alarms?
Is your home a town house or row home?		If yes, how many units are in your row?

Is any business conducted within this home?

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

If you rent answer the following questions:
What is the replacement cost value of your personal items?		What deductible would you prefer for your rental policy?
What are your Personal Liability limits for your rental policy?

Optional Coverage
Do you have a need for additional coverages for the following?
	Yes/No	Amount:
Jewelry:
Furs:
Fine Arts:
Guns:
Computers:

2007 © Affordable Insurance Network. All rights reserved. / Privacy Policy