Consumers Insurance Group

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Please note that Consumers Insurance Group transacts business in Pennsylvania ONLY.

Fields denoted with * are required fields.

General Information

Name:

Social Security #:

(123-45-6789)

Address:
(of home to insure)

City:

County/Township:

State:

Zip:

Phone:

* (111-555-1212)

Email Address:

Home Information

Construction Type:

If other, please specify:

Age/Year of Construction:

Home Type:

Home Style:

Square Footage:

Number of Stories:

Distance to Fire Hydrant:

Miles to Fire Station:

Does your home have any of the following? (Please check all that apply)

Woodstove

Pets

Pool

If yes, please explain:

Any other Schedules/Items? (Jewelry, Furs, etc)?

If yes, please list:

Are there any other buildings on the premises?

If yes, please list:

Are there any other residences owned or rented?

If yes, location(s):

Updates

If your home is over 30 years old, please indicate the year updates were made to any of the below areas:

Coverages

Please indicate the desired coverage for the following:

Comments