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Form 4 – Golden Era Insurance
Homeowner/Renter Quote
Date of Quote Effective Date Lead Source
Affinity/Occupation Group Occupation
Number of adults in HH Policy effective date
Company
Form type Policy type
Owelling Information
Year built Square feet Calculate High Value Yes No Renovation Yes No
Occupancy Style type Construction type Roof type
Age of roof Number of units Outside city limits Yes No Basement Yes No
Garage type Pool Yes NoInterior Fenced
Deck Yes No Brush within 50 feet(TX) Yes No Designated Brush Area within 150 feet(TX) Yes No
Prior losses
Note: Use SRN 32-7978(6-08) to obtain Reconstruction Cost information
Discounts/Surcharges
Non-Smoker Yes No Auto/Home Yes No
Home/Life Yes No Sprinkler System Yes No
New Household Yes No Interior Inspection Yes No
CentraI Burglar/Fire Yes No Local Burglar Yes No
Local Fire(TX) Yes No Hail Resistant Roof(TX) Yes No
Year Renovated — Electrical/Heating Year Renovated — Plumbing
Fire Safeguard (CA only) Energy Source
Other
Coverage
Owelling Separate Structures
Personal Property Loss of Use
Personal Liability Guest Medical
Basic Coverage Deductible
Optiono/Coverage
Jewelry Floater jewelry Floater Deductible
Extended Replacement Yes No Fine Arts Floater
Silverware Floater Fur Floater
Gun Floater Loss Assessment
Increased jewelry Increased Computer
Increased Silverware Increased Gun
Increased Securities Child Care
Personal InjuryCovered Not Covered Number of In-servants
Number of Out-servants W/H Tree ShrubCovered Not Covered
Separate Structures Non-Rent Identity Theft
Building Ordinance10% 25% 50% Flood
Earthquake Other
Data Save
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