Krombolz - Sheets - Insurance

Homeowners, Property Owners & Renters Quote Form

General Information

First Name:

Last Name:

Address:

City:

State:

Zip:

Telephone:

Fax:

E-mail:

How did you hear about Krombolz -Sheets?

For Property Owners

Are you currently insured?

Yes No

Expiration Date:

Name of Current Company:

Do you have a renewal notice?

Yes No

Address of Property:

City:

State:

County Name:

Within City Limits?

Yes No

Any Claims in Last 3 Years?

Yes No

For Homeowners

Current Coverage for Dwelling:

Year Built:

Current Coverage for Liability:

Construction: Brick or
Frame

Purchase Price:

Year Purchased:

Mortgage Amount (if new purchase):

Closing Date:

Kitchen	Dinette/Breakfast Nook	Living Room
Den or Study/Office	Dining Room	Family or Recreation Room
Bedroom(s) (Larger than 100 sq. ft)	Bedroom(s) (100 sq. ft or smaller)	Walk-in Closet/Dressing Room (70 sq. ft or larger)
Bathrooms (3 or more fixtures)	Half Bath (2 or less fixtures)	Foyer/Entrance Hall (omit if part of another room)
Finished Basement (omit if counted elsewhere)	Unfinished Basement	Utility or Laundry Room (140 sq. ft or larger)
Finished Attic (omit if counted elsewhere)	Unfinished Attic	Work Room/Storage/Laundry Room (70-140 sq. ft)
Two Car Garage (attached)	One Garage or Carport (attached)	Enclosed Porch/ Breezeway/ Large Open Deck
Brick/Stone Exterior Walls	Brick/Stone Veneer (front wall)	Aluminum/Vinyl Siding
Central A/C (with separate ducts)	Central A/C (using heating ducts)	Fireplace
Extra Large Rooms (more than 250 sq. ft)	Solar Hot Water Heating Panels	Jacuzzi/Sauna (located in the dwelling)
Clay or Slate Pool

For Renters

Personal Property Amount:

Number of Apartments:

Construction: Brick Frame

Number of Roommates:

Fire Resistive (concrete floors & walls):

Yes No

Waterbed Liability (damage to apartment below):

Yes No

For Condominiums

Personal Property Amount:

Number of Units:

Construction: Brick Frame

Number of Roommates:

Fire Resistive (concrete floors & walls):

Yes No

Building Additions & Alterations:

None $5,000 $10,000

Loss Assessment Coverage:

None $5,000 $10,000

Complete for all forms

Personal Liability:	$100,000 $300,000 $500,000
Deductible:	$250 $500
Smoke Alarm:	Yes No
Burglar Alarm:	Yes No
Central Station:	Yes No
Scheduled Personal Property Amounts:	Jewelry: Furs:
Water Backup Coverage:	None $5,000 $10,000 $25,000
Business on Premises:	Yes No
	Type of Business:
Describe any losses in last three years:

Please review the following information that you have entered. If all the information entered is correct, then click on the "Submit" button below.

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