Maine Home Insurance Application

Name:*

Business Name:

Address:*

City:*	State*:	Zip:*

Day Phone:*

Fax:

Email:*

Occupation (s):

Home Information:

Street Address of Property:

Within 1000' of fire hydrant Yes No

Within 5 miles of Fire Station Yes No

Year House Built:

Year of improvements / updates: (mm/yyyy)
Roof: Electrical System:

Circuit Breakers: Yes No

Year of improvements / updates: (mm/yyyy)
Plumbing: Heating:

Type of Primary Heat:

Wood Stove: Yes No

Type of House:

Occupancy is Primary Home Seasonal Home
Is home ever rented to others? Yes No

Coverage Requested:

Amount of Dwelling Coverage:

Amount of coverage for Detached Structures:

Liability Limit:

Medical payments:

Deductable:

Coverage Options:
Replacement cost contents.
Replacement cost dwelling.
Earthquake coverage
Flood Insurance
Back up of sewer or drain

Remarks: please include any special coverage items you are
interested in, such as antique or jewelry schedules, etc.

Other Information I'm interested in:
Umbrella liability Insurance
Yacht or Boat Insurance

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