Home Quote Request | Somerset Insurance Solutions

Effective Date*

Name*

First Last

Date of Birth*

Gender*

Male
Female

Marital Status*

Single
Married

Property Information

Address*

Street Address Address Line 2 City ZIP Code

Occupancy*

Primary Residence
Leased to Tenant(s)
Secondary/Vacation Home

Mailing Address*

Street Address Address Line 2 City ZIP Code

Purchase Date*

Estimate OK

Build Quality*

Square Footage*

Full Bathrooms*

Half Bathrooms*

Roof Material*

Age of Roof*

Garage Type*

Floor Material*

Laminate
Vinyl
Hardwood
Tile
Marble
Carpet
Custom/Other

Check all that apply.

Central A/C*

Yes
No

Interior Fire Sprinklers

Yes
No
Garage only

Additional documentation is required for discount

Home Security*

Fire Only
Burglar Only
Both
None

Copy of monthly invoice required for discount

Swimming Pool*

Yes
No

Dog(s)*

Yes
No

Breed(s)

Please list the breed of each dog

Insurance Coverage

Personal Liability*

Property Deductible*

Endorsements*

Jewelry Floater
Fine Art Floater
Firearms Floater
Home Business
Not Applicable

Personal Umbrella*

$1,000,000 coverage
$2,000,000 coverage
$3,000,000 coverage
$4,000,000 coverage
$5,000,000 coverage
I choose to decline coverage at this time.

A personal umbrella policy adds an additional layer of liability protection. It is a critical component of a complete insurance plan and strongly advised for homeowners. Coverage should, at a minimum, equal client's net worth.

Additional Information

Professional Discount*

Phone*

Email*

Enter Email Confirm Email