Neway Insurance - Coverage Specialties

Your Name:

Name of insured (If not the same):

Insured date of birth: (MM/DD/YYYY)

Address:

City:

State:

Zip:

Phone:

E-mail:

Fax:

How would you like to be contacted?

Residence to be insured:

Address:
City:
Township:
County:
State:
Zip:
Responding fire department:
Miles from fire department:
Within 1000ft of fire hydrant:

About your residence:

Number of families:	(if other, describe)
Market Value:
Square Feet:
Construction:	If brick, what percent
Year of Construction:
Age of Roof :
Age of Furnace:
Age of Plumbing:
Age of Wiring:
	Do you have a swimming pool?
	Do you have a trampoline?

Safety:

	dO YOU HAVE SMOKE DETECTORS?
	DO YOU HAVE AT LEAST ONE FIRE EXTINGUISHER?
	DO YOU HAVE A WOODBURNER? NOTE: A FIREPLACE IS NOT A WOODBURNER.
	DO YOU HAVE DEADBOLT LOCKS?
	DO YOU HAVE AN ALARM SYSTEM?

You and Your Family:

	Does anyone in your household smoke?
	Is there any business on premises? (ex: avon, woodworking, beauty salon)
	Have you been canceled or non-renewed by an insurance company?
	HAVE YOU PLACED A CLAIM WITH ANY homeowner's INSURANCE COMPANY IN THE PAST 5 YEARS?
	DO YOU HAVE animals? PLEASE LIST THEM. IF YOU HAVE DOGS, NOTE THEIR BREEDS.
	are you a member of any group? (AArp, mea, credit union, college alumni, etc)

Coverage and Deductions:

Current homeowner's insurance company:
	HOW MUCH COVERAGE DO YOU WANT ON YOUR DWELLING?
	SELECT DESIRED DEDUCTIBLE.
	SELECT DESIRED LIABILITY LIMIT.
	SELECT DESIRED GUEST MEDICAL PAYMENT LIMIT.

FYI:

Some companies offer substantial savings on both your Auto and Homeowners Insurance rates when they write both. Check here if you are interested in a combined quote, and fill out our Auto Quote form.