Triumph Homeowners-Condo Quote Form

* Indicates Required Field
Title: *	First name: *	Last name: *

Home Phone #:

Work Phone #:

Cell Phone #:

E-mail address :

How should we contact you during business hours?

Street address of home ⁄ condo to insure: *

City: *	State: *	Zip Code: *

How long at this address?

If you have lived at the home ⁄ condo you want to insure for less than 3 years, what was your prior address?

Prior street address:

City:	State:	Zip Code:

Do you have homeowners ⁄ condo ⁄ renters
insurance currently?

If so, Expiration Date: / /
Month ⁄ Day ⁄ Year (XX ⁄ XX ⁄ XXXX)

If so, name of current homeowners ⁄ condo ⁄ renters insurance company:

For how much do you want to insure your residence? $ *

Desired Deductible: $

When do you want this policy to begin? Month⁄Day⁄Year (XX ⁄ XX ⁄ XXXX) / /

Do you have auto insurance currently?

If so, Expiration Date: / /
Month ⁄ Day ⁄ Year (XX ⁄ XX ⁄ XXXX)

If so, name of current auto insurance company:

Dwelling Information

Type of Residence: *

Year Built: *

If Townhouse, # of
Units in Group: *

Not Applicable
# Units:

Type of Construction: *

# Square Feet of Entire House:
(excluding bsmt/attic)

# Stories (excluding bsmt/attic):

Usage:

Type of Heat:

# Miles from Nearest Fire Department:

Within 1,000 Feet of Fire Hydrant:

Type of Wiring:

Type of Roof: *

Any Upgrades to:

Wiring:

If Yes, when:

Heating ⁄ AC:

If Yes, when:

Plumbing:

If Yes, when:

Roof:

If Yes, when:

Alarm System:

Deadbolt Locks:

Smoke Alarms:

Sprinklers:

Fire Extinguisher:

Any Supplemental Heating:
(fireplace, wood stove, etc.)

Swimming Pool:

Any Claims During Past 5 Years:

Coverage Information

If you have your policy readily available, please complete the following information. If you don’t have your policy available, then you can leave the following information blank:
Coverage A – Dwelling (or Additions/Alterations):	$ *
Coverage B – Detached Structures:	$
Coverage C – Personal Property:	$
Coverage D – Loss of Use:	$
Coverage E – Personal Liability:	$
Coverage F – Medical Payments to Others:	$
[Note: The standard homeowners ⁄ condo policy provides certain amounts of coverage for valuable items (such as jewelry, furs, fine arts, silverware, musical instruments, guns, coins, stamps and collectibles). Please let Triumph know if you want coverage for any of these items beyond the amount of automatic coverage provided.]

Applicant Information

	APPLICANT	CO-APPLICANT
First Name Middle Name Last Name	* *
Gender	*
Marital Status	*
Relationship	Self
Date of Birth Month ⁄ Day ⁄ Year XX ⁄ XX ⁄ XXXX	/ / *	/ /
Comments: