Wes Connor Agency Inc

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Type of Insurance:

Home Details

Year Home Was Built:

Number of Stories:

Type of Property:

Type of Garage:

Type of Basement:

Home Security:

Type of Roof:

Exterior Walls:

Inside Your Home

Square Footage (excluding basement):

Number of Bedrooms:

Number of Full Bathrooms (with shower/bath tub):

Number of Half Bathrooms (without shower/bath tub):

Number of Fireplaces:

Number of Decks:

Potential Discounts:

Deadbolts
Smoke Alarms
Fire Extinguishers
Nearby Fire Station
Nearby Fire Hydrant

Add-ons:

Central A.C.
Sauna
Hot Tub
Wood Burning Stove
Sump Pump
Swimming Pool

Do you own any dogs of these breeds?

Rottweiler
Pitbull
German Shepherd
Chow
Doberman

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Do you currently have home insurance coverage?

Current Insurance Carrier:

When does your existing policy expire?

Estimated Replacement Cost:

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Deductible:

Liability Protection:

Do you need sewer backup protection?

Yes
No

Do you need earthquake protection?

Yes
No

Is there a smoker in your household?

Yes
No

Claims

How many claims would you like to report within the last 5 years?

First Claim:

Second Claim:

Third Claim:

Fourth Claim:

First Claim:

Second Claim:

Third Claim:

Fourth Claim:

Fifth Claim:

First Claim:

Second Claim:

Third Claim:

Fourth Claim:

Fifth Claim:

Sixth Claim:

Valuable Items

What additional valuable items would you like to insure? (check all that apply)

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Address:

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First Name:

Last Name:

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Office: (704) 665-5340

Home Insurance Wizard

Home Details

Inside Your Home

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Info

Claims

Valuable Items

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