Dave Manning Insurance Agency, Inc.
Office: (503)257-3162
REQUEST HOME OWNERS INSURANCE
Personal Information:

Your Full Name: Date Of Birth:
Spouse Full Name: Date Of Birth:
City: State: Zip: County:
Phone number where you would like to be contacted:
Best time to reach you?
Email address to send information:
Do you own your own home, or do you rent?
Is this a condominium or townhouse unit:

 

General Information About Your Home:
 
Year of construction of home: Total square feet: Style of home:
Type of garage:
Is the garage attached or detached from your home?
Is there built-in living space above the garage?
Is this a normal tract home, or is it custom built?
How many full baths? How many half baths? How many fireplaces?
Roof type (I.e. wood shake, etc.):
Exterior of home (I.e. stucco, etc.):
Is there a burglar alarm?
Is there a separate Jacuzzi / hot tub? Wet bar?
Are there fire sprinklers in the attic?
Is this a new home purchase? If yes, escrow close date:
 

Policy Information:
 
Name of current insurance carrier: Renewal date:
Number of losses the past three years: Amount paid if known:
Non-smoker? Are you over the age of 50?
Any special riders, increased coverage limits on certain items, i.e. jewelry, fine arts etc.
Are you interested in earthquake and various options available?
Do you have an Umbrella liability policy? Auto Carrier?