Zolofra Insurance
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Toll Free: (888) 858-1777
Fax: (732) 334-0405

First Named Insured (First & Last Name to be listed on policy)

Date of Birth of First Named Insured (include month, day and year)

Marital Status?

Second Named Insured (First & Last Name to be listed on policy)

Date of Birth of Second Named Insured (include month, day and year)

Phone number

Social Security Number/First Named Insured

Social Security Number/Second Named Insured

Occupation/First Named Insured

Occupation/Second Named Insured

Email address

Street Address (of home to be insured)

City (of home to be insured)

County (of home to be Insured)

State (of home to be Insured)

Zip Code (of home to be Insured)

How long have you lived at this address?

Have you filed for bankruptcy within the last 7 years?

Who is your current homeowners insurance company?

What date does your homeowners policy expire?

What is your annual homeowners premium?

For discount purposes, who is your current auto carrier and what is the current policy #?

Desired deductible on this policy?

Desired liability limit on this policy?

Do you currently have an umbrella policy?

Billing Street Address (if different than property being insured)

Billing City (if different than property being insured)

Billing County (if different than property being insured)

Billing State (if different than property being insured)

Billing Zip Code (if different than property being insured)

Purpose of this property:

If this is your rental property, is it currently occupied by a tenant?

Is this property currently under construction?

Was this property purchased as a foreclosure or short sale within the past 12 months?

Purchase Price of home

What is the current market value of the property?

Current Mortgage Amount Owed

Name of Bank

Make this insurance payment part of your mortgage payment?

How many mortgages do you have on this home?

What date did you purchase this property?

What is the distance to the nearest fire hydrant?

What is the distance to the nearest fire station?

What is the name of the closest Fire Department?

Is this fire department a paid or volunteer service?

Identify the type of features and systems you have in your home:
 Local Alarm (Fire and Burglar) Central Fire Central Burglar Sprinklers Gated Community Temperature Monitoring Back-up Generator Smoke/Fire Fire Extinguishers Dead Bolts Visible to neighbors None of the above

Does this property have electric circuit breakers?

Age of Home:

Home type: # of Families

How many occupants?

Construction Type:

What type of building materials are on the exterior of your home? (i.e. aluminum, vinyl, cedar, brick, EIFS/stucco, etc.)

Number of stories (not including basement)

Style of house (ranch, colonial, split, cape, condo, etc)

Overall square footage of living space.

How many bedrooms?

How many full bathrooms?

How many half bathrooms?

Do you have any specialty rooms (study, exercise) if so, please identify type.

Do you also have any of the following? (check all that apply)
 Decks Porches Patios Custom kitchens/baths Cathedral ceilings Fireplaces Attached Garage Detached Garage Central Air Jacuzzis Solar Panels on Roof None of the above

Your home’s inside walls are composed of? (i.e. sheetrock, plaster, block)

The inside walls of this property contain (check all that apply):
 paint wallpaper ceramic tile marble/granite paneling

The floors of this property contain (check all that apply):
 wood parquet laminant cork ceramic tile marble/granite carpet



What type of roofing materials does your home have?

Is your roof pitched or flat?

Do you have any custom windows? If so, advise how many and type.

 None, on a slab Crawlspace Finished Unfinished Partially finished Partial basement

If you have a basement, what percent of the basement is finished?

If you have a basement, is it a walk-out basement?

If you have a basement, do you have a sump pump?

If you have a sump pump, do you have a back up power source in case of power failure?

Type of heat (check all that apply):
 Above ground oil tank Below ground oil tank Electric Natural Gas Forced Hot Air Wood stove Radiant Kerosene Coal Burner Propane Solar Panels

Is there a fuel tank on this property?

If yes, is it located in your basement, underground or above ground?

What year was the wiring updated/renovated?

What year was the plumbing updated/renovated?

What year was the heating updated/renovated?

What is the age of the roof?

Regarding your exterior, please check all that apply:
 Above ground pool Inground pool Pool has a slide Pool has a diving board Pool is fenced Trampoline(s) on premises I am willing to remove the trampoline(s) within 30 days None of the above

Is this property undergoing renovations or any reconstruction?

Is this property currently for sale?

Do you have any other structures on your property not mentioned here? Please describe.

Have you had any losses in the past 3 years?

An insurance score report will be required to deliver an accurate quote. Do we have your permission to obtain your credit score?

Is this property within 2 miles of tidal water?

Any foreclosure, repossession, bankruptcy, judgment or lien against you in the past 5 years?

In the past 5 years, have you been convicted of the crime of arson in any degree?

Are there any uncorrected fire or building code violations on this property?

Is there a lead paint hazard on this property?

If you live in an association, do you pay a maintenance fee? If so, are you interested in increased Loss Assessment Coverage?

If yes to losses, please advise on type of loss, date of loss and payments:

If you have pets, please advise on type of pet and breed. Please advise on any bite history

Would you like to have any jewelry, furs, fine arts or silverware insured also? If so, please advise on type and value below.

Do you have any full-time domestic workers, nannies or caretakers? If so please advise below.

Are you interested in obtaining quotes on higher limits of liability?

If yes to higher limits, please list the locations, # of vehicles and underlying limits:

List the names, dates of birth, driver license #’s and the underlying carriers for each youthful driver.

Do you also own any of the following? (check all that apply)
 Minibikes Mopeds Motorcycles Motorhomes Aircraft Snowmobiles Golfcarts None of the above

Regarding any owned watercraft, please identify the type, size of vessel and horsepower.

Please provide a copy of your current homeowners declarations page via email to ben@zolofrainsurance.com or fax to 732.334.0405.

Did we miss anything? Include additional comments here.

Disclaimer Notice – The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.

Please utilize the “Send” Button to send your form to our office. If the website does not allow you to submit the form, please print the page and fax it to 732.334.0405 or scan it into your computer and send it to ben@allprocoverage.com. Do not “Refresh” the page because all data entered onto the form will be lost.

After you hit the “Send” button, please scroll back down to this area and if successfully sent, a message will appear below. If not successfully sent, a message will appear below which means you have to scroll back up and complete the missing information, which typically involves entering information into a highlighted box. Complete the missing information and then hit “Send” again. Thank you!

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Zolofra Insurance Agency
P.O. Box 868
Oakhurst, NJ 07755
Toll Free: (888) 858-1777
Direct: (732) 542-1757
Fax: (732) 334-0405
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