South Shore Insurance, Inc

Christine J Newton Agency 760 S Calumet Rd Chesterton, In 46304

Home Quote Sheet

Agent:
Date Received:
Date Needed:
Referred by:
Insured Name:
Resisdence Address:
Mailing Address:
Home:
Cell:
Work:
Email:
Insured Information:
Name:
Date of Birth:
Social Security:
Driver's License:
Marital Status:
Education:
Name (2):
Date of Birth (2):
Social Security (2):
Driver's License (2):
Marital Status (2):
Education (2):
Current Carrier/premium:
Renewal:
Lapse?:
Closing Date/Purchase Date:
Escrow:
Self-Pay:
Mortgage Contact:
Year Built:
Construction Type: Brick:
Frame:
Foundation:
Finished:
Square Footage:
Stories:
Style:
Pool:
Above Ground / In Ground / Other:
Diving Board
Slide:
Fenced:
Pets:
*Updates:
Roof
Furnace
Plumbing
Wiring/Electric:
Air Conditioning:
Circuit Breakers
*Security:
Central
Fire
Police
Smoke Alarms
Air Conditioning:
Extinguisher
*Coverages:
Dwelling
Personal Property
Liability
Medical
Sewer Back-up:
Deductible
Business on Premises
*Scheduled Items: (Jewelry, furs, watches, guns, collectibles):
Security Check:


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