Dixon Financial & Insurance Services

Name:

Street Address:

City:

State:

Zip Code:

Home Phone:

Cell Phone:

Marital Status:

SingleMarriedDivorcedWidowed

Date of Birth:

Use:

Primary ResidenceSecondary ResidenceRentalVacation

Replacement Cost

Year Built:

Date Purchased:

Square Footage:

Number of Storied:

Liability Limit

Deductible

Current Carrier:

Current Premium 

Current Renewal Date:

xx

Garage:

AttachedDetachedCarport

Garage Size:

1 Car2 Car3 Car

Foundation: 

SlabCrawl SpaceBasement

External Walls

Stucco Over FrameT-111 SidingOther

Roof:

Asphalt ShingleTileFlat TopOther

Kitchen:

StandardCustomDesigner

Bathroom:

StandardCustomDesigner

# of Bathrooms

Heating / AC:

CentralGas HeatWindow AC

Flooring:

HardwoodCarpetVinylTile

Percent of Hardwood

Percent of Carpet

Percent of Vinyl

Percent of Tile

Total Percent of Flooring

Alarm:

NoneLocalCentral Reporting

Gated Community:

NoYes

Dog:

NoYes

If Yes, Type of Dog

Current Carrier:

Current Premium:

Current Renewal Date:

Electrical Update:

NoYes

Year:

Heating Update:

NoYes

Year:

Plumbing Update:

Year:

Roof Update:

NoYes

Year:

Fireplace:

NoYes

Type:

Wood BurningGas

Auxiliary Heating:

NoYes

Swimming Pool

NoYes

Trampoline:

NoYes

Anchored to Ground:

NoYes

Safety Net:

NoYes

Under Construction:

NoYes

Vacant / For Sale:

NoYes

Interior Sprinklers:

NoYes

Smoke Decetors:

NoYes

Any Losses in the Past Three Years:

NoYes

--If Yes Supply Details:

Date:

Type:

Amount of Loss:

Additional_Losses:

NoYes

$1500 Jewerly

$2500 Collectibles / Memorabilia

$1500 Musical Instruments

$200 Money / Coins

$1500 Stamps

$1500 Furs:

$2500 Firearms:

$2500 Silverware / Goldware: 

$2500 Business Personal Property::

$500 Cameras / Video Equipment:

$1000 Paintings:

$1500 Securities / Important Papers:

$1500 Trailer:

Do You Own:

BoatJet SkiMotor HomeATVGolf CartCamping Trailer/5th WheelMotorcycle/Dirt Bike

Are You Interested in Identy Theft Protection:

NoYes

Earthquake Coverage:

NoYes

Flood Coverage:

NoYes

How Would You Like to Receive Your Quote:

PhoneE-mailUSPSIn Person