Homeowner/Contact
Information
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Todays Date:
(mm/dd/yyyy)
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* Owner's First Name:
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* Owner's Last Name:
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* Street Address:
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* City:
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* State:
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* Zip:
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* County:
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* Valid Email Address:
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* Home Phone:
(999-999-9999)
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* Work Phone:
(999-999-9999)
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* Owner's Date of Birth:
(mm/dd/yyyy)
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* Owner's Gender:
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Owner's
Social Security Number:
(e.g. 555-55-5555l)
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* How would you (owner)
describe your credit rating?:
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Poor
Good
Excellent
Unsure |
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* Current Residence Status:
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* Length of time at current
residence?:
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Best
time to contact you?:
Best
way to contact you?:
Email Phone
Work Phone |
* How quickly do you need your
request processed?:
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Please
provide any comments you have:
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Are you
interested in a multiple-policy discount (for auto and home insurance)?:
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Yes
No |
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* Are you currently (or have
you ever been) a Clark customer?
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Yes
No |
* How did you hear about Clark?
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Other: Please Specify
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Insurance
Information
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| Please
tell us more about your current or recent insurance policy. Be as
accurate as possible. |
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* Your most current insurance
company:
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* What date does your current
policy expire/renew?
(mm/dd/yyyy)
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* How long have you been
insured with your current insurance company?:
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* How long have you been continuously
insured with this company?
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Property
Location and Type
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* Address of the property to be
quoted:
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Address
2 or Apt. Number:
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* City/Township:
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* County/Parish:
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* State:
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* Zip Code:
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* Please select the property
type:
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* Do you currently own (or are
you in the process of purchasing) this property?:
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Yes No |
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* Do you now reside, or plan on
residing at this property within the next 12 months?:
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Yes
No
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Property
Coverage Information
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* How much Residence coverage
do you want?:
(In dollars, for example:
250,000)
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* How much personal liability
coverage do you want?:
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* How much deductible?:
(The higher your deductible, the lower your premiums)
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* Approximate year property
built:
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* Approximate livable square
footage of residence:
(excluding basement, if any)
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* Is this your primary or
secondary residence?:
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* Is business or farming
conducted on this property?:
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Yes
No |
* Do you have any of the
following breeds of dogs: Chow, Doberman, German Shepherd, Pit Bull,
Rottweiler, Wolf Hybrid, or mix of these?:
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Yes
No |
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* Dwelling design:
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* Exterior wall type:
(60% or more)
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* Number of Bedrooms:
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* Number of Bathrooms :
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* Roof Type:
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* Roof Age:
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* Garage Type:
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* Describe Foundation or
Basement:
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* Wiring Type:
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* Service Panel Type:
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* Central Burglar Alarm:
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* Central Fire Alarm:
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* Fire Station:
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* Fire Hydrant:
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* Municipal Location:
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* Please describe the heating
system in this dwelling:
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* Number of gas, pellet or wood
fireplaces or stoves:
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* Is your home prone to
flooding or located in a designated flood plain?:
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* Property Accessories
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Claims
Information
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Claim
Type:
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Date of
Claim:
(mm/dd/yyyy)
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Claim
Type:
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Date of
Claim:
(mm/dd/yyyy)
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Claim
Type:
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Date of
Claim:
(mm/dd/yyyy)
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