Nichols Insurance Services - Homeowner Insurance Form

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For more information, please fill out the form below and
we will contact you as soon as possible. Thank You.

YOUR INFORMATION
First Name
Last Name
Address
City
State
Zip
E-mail
POLICY INFORMATION
Policy Type
Number of Units
Number of Stories
Year Built
Total Square Feet
Ground Floor Square Feet
Construction
Foundation
Type of Roof
Roof Last Replaced (date)		Month Year
Updates:
Plumbing
Heating
Electrical System
Local or Central Alarm
Central Air
Home Bolted to Foundation
Number of Fireplaces
Number of Full Bathrooms
Number of Half Bathrooms
Number of Bedrooms
Type of Garage
Number of Cars
Size of Decks
Size of Porch
Size of Balcony
Swimming Pool ?		Yes No
If yes, is it fenced in ?		Yes No
Any Pets?		Yes No
Brush area and vegetation
Miles to fire department
Feet from Fire Hydrant
Any detached structures?		Yes No
Any in-home businesses?		Yes No
Please describe other structures:
Is Home retrofitted for earthquakes?
Prior losses (the past 5 Years)
Any Specialty Rooms? (Check all that apply)
Study Library Formal Dining Room Laundry Room Great Room Office Recreation Room
General Shape of Residence?
Rectangular L-Shape Unique Very Irregular
Special Features? (Check all that apply)
Hardwood Floors Marble/Granite Floors or Countertops Brick or Stone on Exterior Walls Woodwork Throughout Central Vacuum
Schedule Articles:
Current Insured Value
Dwelling		Personal Liability
Personal Property		Medical Payments
Personal Injury		Deductible
Earthquake Coverage		Earthquake Deductible
Ordinance & Law
Insurance Carrier
Expires		Month Year