VMG

Versatile Management Group

Home

Business

Auto

Life

www.4vmg.com

Working with prosperity on our mind to insure your peace of mind.

Homeowners Insurance

STRUCTURAL INFORMATION

What is the style of your home? 

How many stories is your home?  

How many rooms do you have? 

What is the total square footage of the living  area of your home?  

WHAT IS THE STRUCTURE OF THE FOLLOWING?

Roof:  Exterior of your home: 

Foundation:Basement: 

Inside walls:        Flooring: 

Garage: 

What is the replacement cost of your home:  $

HOW MANY OF THE FOLLOWING DO YOU HAVE IN YOUR HOME?

Full bathrooms:  Half bathrooms: 

Fireplaces:         Decks: 

Enclosed porches:     Open porches: 

DO YOU HAVE THE FOLLOWING IN YOUR HOME

Swimming pool?  Trampoline? 

Burglar alarm?     Sprinkler system? 

Kerosene, wood or oil stove?         Dog? 

Computer?                      Livestock? 

Unusual/exotic pets? 

IS YOUR HOME LOCATED...

Within 1000 feet of a fire hydrant? 

Within 5 miles of the firestation? 

On a hillside? 

Close to a body of water or susceptible to flooding? 

GENERAL QUESTIONS

Year home built:  

Number of families living in the home: 

What part of the year is the home occupied? 

Heating and cooling system:  

What term best describes your kitchen? 

Is business conducted on the premises? 

Does anyone in your home smoke? 

Did you experience any loss or claims in the last 5 years? 

PROTECTIVE DEVICES

Deadbolt locks?

Smoke detectors?  Fire extinguishers?                Fire alarm? 

ADDITIONAL INFORMATION

Gated community with a security guard: 

Neighborhood watch program: 

Senior citizen discount (all occupants age 55 or above):

HOMEOWNERS COVERAGES AND DEDUCTIBLES

Dwelling (Coverage A - Replacement cost of your home): $  

Other structure (Coverage B - Typically 10% of coverage A): 

Personal property/contents (Coverage C - Typically 50% of coverage A):

Loss of use of your home (Coverage D - Typically 20% of coverage A):

Personal liability:   Medical payments:  

Desired deductible: 

ADDITIONAL DATA

Quote requested within: 

Do you want an umbrella quote: 

OPTIONAL QUESTIONS

Do you have a collection of anything of value such as coins, stamps, art etc.?

If ues, please estimate the value of your collection: $  

If you have any furs or jewelry, please specify the approximate value/limits: $  

Do you have any special interests or hobbies that could be  considered a home based business? 

Do you travel? Do you travel outside of the United States? 

When you travel, do you take valuables such as watches, jewelry, or furs with you? 

Do you buy things while traveling and want them immediately insured under your policy? 

If your home were destroyed, would you want to rebuild it in the same location? 

Do you have/want backup of sewers and drain coverage?  

Copyright (c) 2005 Versatile Management Group, LLC - All Rights Reserved

PERSONAL INFORMATION

First Name:  

Last Name:  

E-mail address:  

Daytime Phone Number:       May we contact you at this number during the day?

Alternate Phone Number:       Is this a 

Fax Number:  

How would you prefer to be contacted regarding your quote? 

If you would prefer to be contacted by phone, please let us know the best time to call. 

Address:  

City:   State: Zip code:  

Social Security number:  

Occupation:   Employer:

Date of birth:   Gender:

To help us supply you with the most accurate quote possible, please answer all sections applicable to the coverage you are inquiring about.  If you are unsure of anything, please answer as many questions as you can with the most accurate information available to you.

Information submitted will be held confidential and will be used for quote purposes only. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

Once you have completed the above application, please review your answers checking for accuracy. 

To send your information to a qualified representative, please click on the submit button below. 

You will be contacted once your information is reviewed.

Would you like information on other services provided by Versatile Management Group?  Click Here

Welcome

Return to Homepage

YesNo

Cell PhonePagerHome (evening calls only)

PhoneFaxE-mailMail

AMPM

MaleFemale

select one...AdobeBungalowCape CodColonialContemporaryDuplex Log HomeMediterraneanQueen AnneRaised Ranch (Bi-Level)RanchSplit Level Timber FrameTraditionalTri-LevelVictorianOtherOption #2

select one...1 story1 1/2 stories2 stories2 1/2 stories3 stories4 or more storiesBi-levelTri-levelOption #2

select one...123456789or moreOption #2

select one...Architectural Shingles Asphalt Shingle Built Up - Tar & Gravel Clay Tile Concrete Tile Corrugated Steel Fiber Shingles Mineral Fiber ShakesMission Tile Rock Roof Roll Roofing Rubber Roof Slate Tin Wood Wood Shake  Other

select one...Adobe Aluminum Siding Asphalt Brick Veneer Brick Solid Cement Fiber Clapboard Concrete Block Concrete-Precast Logs Log Siding Mineral Fiber Painted Masonry Slump Block Split Block Stone-Precast Stone-Solid Stone-Veneer Stucco-On-Frame Stucco-On-Masonry Wood Shakes Wood Siding Other 

select one... Slab on Grade Crawl Space Piers/Pilings/Stilts

select one...Unfinished Basement 25% finished basement 50% finished basement 75% finished basement 100% finished basement Walkout basement Wood foundation basement 

most consist of...Brick Ceramic Tile Cork Grass Cloth Knotty Pine Mirror Paint Paneling Stone Wallpaper Other 

most consist of...Carpet over Hardwood Ceramic Tile Flagstone Hardwood Parquet Slate Wall to Wall Carpet Other 

select one... None Attached - 1 car Attached - 2 car Attached - 3 car Basement - 1 Car Basement - 2 Car Basement - 3 Car Built-in - 1 car Built-in - 2 car Built-in - 3 car Carport - 1 car Carport - 2 car Carport - 3 car Carport w/storage - 1 car Carport w/storage - 2 car Detached - 1 car Detached - 2 car Detached - 3 car 

select one... None 1 2 3 or more 

select one... None 1 2 3 or more 

select one... None 1 2 3 or more 

select one... None 1 2 3 or more 

select one... None 1 2 3 or more 

select one... None 1 2 3 or more 

Yes  No

Yes  No

select one... None Local Central Police Station 

select one... None Some rooms All rooms 

Yes  No

Yes  No

Yes  No

Yes  No

Yes  No

Yes  No

Yes  No

select one...01234 or more 

select one...Year round Seasonal (or Snowbird) Occasional Vacation None (Vacant) 

select one... Economy Standard Custom Designer 

Yes  No

Yes  No

Yes  No

Yes  No

Yes  No

select one... LocalCentralFire station 

Yes  No

Yes  No

Yes  No

Yes  No

select one... $30,000 $35,100 $40,250 $45,250 $50,400 $55,500 

select one... less than $150,000$150,000 $165,000 $180,000 $195,000 $210,000 $225,000 $240,000 $250,000 or more

select one...$60,000$80,000 $100,000 $120,000 $140,000 $160,000 $180,000 

select one... $1,000 $2,000 $3,000 $4,000 $5,000 $7,500 $10,000 $25,000 

select one... $1,000 $2,000 $3,000 $4,000 $5,000 $7,500 $10,000 $25,000 

select one... $250 $500 $1,000 $2,500 $5,000 

24 hrs   48 hrs   72 hrs    120 hrs

Yes No I don't know 

Yes  No

Yes  No

Yes  No

Yes  No

Yes  No

Yes  No

Yes  No

Yes  No

Yes  No