Individual Home Insurance Form
Simply fill out Hamlin Clark Insurance's quick and hassle free home insurance application.
Click 'submit' and we will be in touch with you within 48 hours.

NOTE: All information submitted by prospective clients will be kept in strict confidence and all applicable insurance institution privacy laws.
Email address *
First & Last Name *
Phone Number *
Date of Birth
SSN
Occupation
Co-Applicant Name | DOB | SSN | Occupation
Address & County
Property Location (if different)
Feet to Hydrant
Miles to Fire Station
Township (if not in city limits)
Form:
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Present Carrier | Policy # | Expiration Date
Premium Paid Escrow or Insured | Frequency of Payments
Current Limits: Coverage A, Dwelling
Current Limits: Coverage E, Liability
Current Limits: Deductible
Current Limits: Current Market Value
Current Limits: Current Mortgage Amount
Are All household residents Non-Smokers?
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Alarm System?
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If yes to Alarm System, is it local, police, or central? Company?
Smoke Detectors?
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Fire Extinguisher?
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Dead Bolt Locks?
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Sump Pump?
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Wood Stove?
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Swimming Pool?
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If Yes to Swimming Pool, Above Ground, Below Ground, Diving Board, Slide, Fence Height, Fence Lock?
In-Home Business?
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If Yes to In-Home Business, what type of business?
Watercraft?
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Trampoline?
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If Yes to Trampoline, is it netted?
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Hot Tub?
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If Yes to Hot Tub, is it locked?
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Dogs?
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If Yes to Dogs, how many and breed?
Group Discounts - Check All that Apply
Please list association names below to the above question:
Plumbing - Year Updated | Any Claims in the last 5 Years (date, type, and amount paid)
Electrical - Year Updated | Any Claims in the last 5 Years (date, type, and amount paid)
Heat - Year Updated | Any Claims in the last 5 Years (date, type, and amount paid)
Roof - Year Updated | Any Claims in the last 5 Years (date, type, and amount paid)
Scheduled Personal Property Jewelry - # of Items | Total Value
Scheduled Personal Property Furs - # of Items | Total Value
Scheduled Personal Property Fine Arts - # of Items | Total Value
Replacement Cost Information - Year Built
Replacement Cost Information - # of Families
Replacement Cost Information - # of Stories
Replacement Cost Information - Square Footage 1st Level | 2nd Level | 3rd Level
Replacement Cost Information - % of Lowest Level Built Over Basement | Crawl Space | Slab | Walkout Basement
Exterior Wall Material in % - Brick Veneer | Vinyl Siding | Aluminum Siding | Wood Siding | Cedar | Hardy Board | Half Log | Full Log
Garage Type
Additional Structures
If Yes to Additional Structures, square feet of each?
Finished Attic?
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If Yes to Finished Attic, square feet?
Finished Basement
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If Yes to Finished Basement, square feet?
Air Conditioning
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Attached Three-Wall Room Addition
If Yes to Above, Square Feet?
Breezeway?
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If Yes to Above, Square Feet?
Porch?
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If Yes to Above, Square Feet?
Screened Aluminum Enclosure?
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If Yes to Above, Square Feet?
Decks or Balconies?
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If Yes to Above, Square Feet?
Fireplace?
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If Yes to Above, How Many Chimneys?
If Yes to Above, Number of Hearths?
Total Number of Baths
Check all Built-Ins that apply
For any that apply above, please indicate the quantity of each in the home:
Interior Flooring Material in % - Ceramic Tile | Vinyl | Laminate | Hardwood | Carpet Over Hardwood | Carpet Over Subfloor | Pergo | Slate | Other
Interior Wall Material in % - Drywall | Plaster | Crown Molding | Built-in Bookcase
Interior Wall Height in % - 8 ft. | 9 ft. | 10 ft. | Cathedral
Interior Wall Surfaces Material in % - Paint | Wallpaper | Mirror | Sheet Paneling | Solid Wood Paneling | Other
Window Types - Check all that apply
# of Window Types from Above Question
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Countertop Material
Cabinet Material
A copy of your responses will be emailed to the address you provided.
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