Request a Quote
Please complete the following to request a quote from Louis J Brudnick and Sons Insurance. Items that are in
RED
are required to receive a quote.
Applicant Information:
Name:
Address:
City:
Zip:
Home Phone:
Work Phone:
e-Mail Address:
Property Information Section:
Property Address:
City:
Construction Material:
Frame
Masonry
Masonry Veneer
Vinyl Siding
Aluminum Siding
Asbestos Siding
Fire Resistant
Year Built:
"yyyy"
Square Footage:
sq. ft.
# Rooms:
# Apartments:
Market Value:
$
Replacement Cost:
$
Structure Type:
Dwelling
Apartment
Condo
Townhouse
Rowhouse
# Families
# Household Residents:
Is any resident a smoker?:
Select Yes/No
Yes
No
Purchase Date:
"mm/dd/yyyy"
Purchase Price:
$
Distance to Hydrant:
ft.
Distance to Fire Station:
mi.
Wired Alarm Systems
(connections to fire/police authorities):
Fire Alarm?:
Yes
No
yes/no
Burglar Alarm?:
Yes
No
yes/no
Fuel:
Gas
If "Oil" is checked, "Storage Tank Location" below is required.
Storage Tank Location
(ex. "basement"):
Oil
Electric
Wood
Coal
Solar
Please enter Year of Renovation, if applicable, for the items at right.
Electrical:
Plumbing:
Heating:
Roof:
Exterior Painted:
Occupied By:
Owner
Tenant
Please check those which apply:
Deadbolt
Smoke Detector
Fire Extinguisher
Property Visible to Neighbors
Swimming Pool?:
No
Yes
Approved Fence
Diving Board
Above Ground
In-Ground
Roof Type:
ex. "flat/shingle"
General Information:
Please check those which apply.
At Home Business:
Description:
Hazard present for flooding, brush fire, forest fire, landslide:
Description:
Animals/Pets:
Description/Breeds:
Property located within 2 miles of tidal water:
Description:
Property located on more than 5 acres:
Description:
Trampoline on Premises:
Yes
No
General Information:
Please enter the quantity of each type of unit in your home.
0
1
2
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5
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8
9
10
Kitchen
0
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10
Dining Room
0
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10
Living Room
0
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9
10
Den/Study/Office
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Family/Recreation Room
0
1
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9
10
Bedroom(s)
0
1
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9
10
Bathrooms(s)
0
1
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9
10
Large Utility/Laundry/Sewing Rooms (Over 150 sq. ft.)
0
1
2
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5
6
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8
9
10
Finished Basement (Omit if counted as family/rec room)
0
1
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9
10
Attached 2-Car Garage
0
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9
10
Large Finished Attic (Over 150 sq. ft.)
0
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10
Partially Finished Attic
0
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Partially Finished Basement
0
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Brick/Stone Exterior Walls
0
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Central A/C
0
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10
Aluminum/Vinyl Siding
0
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10
Large Wall Fireplace
0
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10
Enclosed Porch/Breezeway
0
1
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9
10
Clay Tile or Slate Roof
0
1
2
3
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8
9
10
Any Other Unit Not Listed Here
0
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10
Half Bath
0
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10
Large Open Porch/Breezeway
0
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10
Standard Fireplace
0
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10
Unfinished Basement
0
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9
10
Attached 1-Car Garage
0
1
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9
10
Built-in 2-Car Garage/Carport
0
1
2
3
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8
9
10
Small Utility/Laundry Sewing Rooms (Under 150 sq. ft.)
0
1
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5
6
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8
9
10
Foyer/Entrance Hall
0
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10
Dressing Room/Walk-in Closet
0
1
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8
9
10
Unfinished Attic
0
1
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3
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5
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9
10
Small Finished Attic (Less than 150 sq. ft.)
0
1
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4
5
6
7
8
9
10
Mudroom (With separate entrance)
0
1
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9
10
Brick/Stone Veneer (Front Wall)
0
1
2
3
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5
6
7
8
9
10
Dinette or Partitioned Breakfast Nook
0
1
2
3
4
5
6
7
8
9
10
Any Other Unit Not Listed Here
General Questions/Comments:
Submit Request
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Louis J. Brudnick & Sons; © 2008
