Our Auto & Home Insurance Carriers
• American Modern
• Chubb
• Colorado Casualty
• Foremost Insurance Group
• Metlife
• Occidental

• Progressive
• RLI
• Safeco
• Sentry Insurance
• The Hartford
• Travelers

Homeowner Insurance Application

Pritchard Group Insurance makes shopping for auto insurance easy. Please fill out as much information as you can at this time to give us a head start on finding the perfect insurance coverage for your needs. Please expect a response within 24-48 hours so that we may research all money-saving opportunities. By filling out this form you are giving permission to Pritchard Group Inc. to contact you by phone to verify or clairfy informatiopn provided.

Contact Name:	*
Street Address:	*
City, State, Zip Code:	*
Home Phone (area code):	*
Business Phone:	*
Cell Phone:
Email:	*
Current Insurance Carrier:
Policy Number:
Current Premium $:
Renewal Date:
Current Insured Value $:
Name of Lein Holder / Mortgage Company:
Lender's Phone Number:
Loan #:
Closing Date:
Do you own Additional Properties?

Title Owner's Name:
Marital Status:
SS#:
Month/Day/Year of Birth:

Additional Title Owner's Name:
Marital Status:
SS#:
Month/Day/Year of Birth:

Employer Name:
Years:
	PRIOR ADDRESS if less than 6 months
Street Address:
Prior City / State / Zip:
Name of Lein Holder / Mortgage Company:
Loan #:
AARP / AAA Member #:

About Your Home

Year Built:

Total Square Footage (living space):

Purchase Date:

Purchase Price $

Market Value: $

# Stories:

Basement?

# Full Baths:

# Half Baths:

Type of Construction:

Type of Roof:

Year Replaced

Garage / Carport:

# Cars:

Covered Patio / Porch sq. ft:

Heating:

Air Conditioning Solar?

Pool:

Fireplace?

Type:

Check all features of your home:

Deadbolts	Smoke Detect.	Fire Alarms
Sprinklers	Alarm: Monitored	Retirement Comm
Hot Tub	Jacuzzi	Trampoline
Wet Bar	Sliding Glass Door	Bay Window
Golf Course Prop	Kitchen Upgrades	Laminate Floors
Ceramic Tiles	Hardwood Floors	Vinyl Floors
Marble Floors	Carpet	Parquet Floors

Household Pets:

Breed:

Personal Liability Coverage:
Medical Payments to Others:
Deductible:
Personal Excess Liability Coverage (Umbrella):
Extended Coverage on Jewelry $:
Description of Jewelry:
Appraised?:
Home Office?:
Number of Computers:
Firearms Value: $
Collectibles Value: $

Please send me a quote based on the information I have provided in this on-line application form.