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Rufus Jackson Agency
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Your Info
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Name
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First
Last
Date of Birth
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Driver's License #/State Issued
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Additional Owner/Driver
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First
Last
[object Object]
Date of Birth
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Driver's License#/State Issued
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Phone
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Email
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Are You a Homeowner?
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Yes
No
Currently Insured - Car
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Yes
No
Currently Insured - Home
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Yes
No
Health Insurance?
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Yes
No
If yes, Carrier and Policy #?
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Premium and Exp Date
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If yes, Carrier and Policy #?
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Premium and Exp Date
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Healthcare Provider
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Your House
Your Vehicles
Year Built
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Model Year
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Make/Manufacturer
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Occupancy Status
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Primary Residence
Secondary Residence
Property Type
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Single Family
Multi-Family
Model Year
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Make/Manufacturer
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Total Living Sq Ft
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# of Stories
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# of Bedrooms
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Upgrades?
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Yes
No
Roof - Year Upgraded
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Heating/Cooling - Year Upgraded
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# of Baths
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Do you have a wood burning stove?
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Yes
No
Plumbing - Year Upgraded
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Electric - Year Upgraded
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Basement Type
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Below Grade
Daylight/Walkout
Garage Type
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Built-in
Attached
Detached
None
Roof Type
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Shingles, Architectural
Shingles, Wood
Shingles, Asphalt/Fiberglass
Shakes/Wood
Exterior Wall
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Brick on frame
Brick, Solid
Shakes, Wood
Siding, Aluminum
Siding, Vinyl
Siding, Clapboard
Siding, Wood
Check all that apply
Interior Features
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Fireplace, Direct
Fireplace, Gas
Attic, Finished
Sliding Glass Doors
Hot Tub
Jacuzzi
Select all that apply
Attached Structures
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Open Porch
Screened Porch
Enclosed Porch
Wood Deck
Redwood Deck
Select all that apply
Basement Finished
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0%
25%
50%
75%
100%
Number of Cars
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1
2
3
4
Security System
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None/Unknown
Complete Burglar Alarm
Alarm to Central Station
Partition Wall
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Block
Drywall
Drywall, textured
Plaster
Select all that apply
Exterior Features
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Door, Atrium
Window, Atrium
Window, Bay
Window, Bow
Skylights, Small
Skylights, Large
Select all that apply
Detached Structures
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Hot Tub/Jacuzzi
Shed, Small (6' x 16')
Shed, Medium (20' x 40')
Shed, Large (30' x 50')
Swimming Pool Above/Inground
Select all that apply
Model/Body Style
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VIN
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Model/Body Style
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VIN
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Additional Drivers
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Current Vehicle Liability Coverage
Vehicle 1
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20K/40K
100K/300K
250K/500K
Vehicle 2
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20K/40K
100K/300K
250K/500K
Comp
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Yes
No
Comp
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Yes
No
Collision
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Yes
No
Collision
*
Yes
No
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