J.E. Brown & Associates

American Modern Dwelling Fire

Client Information

First Name

Middle Name or Initial

Last Name

Property Information

Address or Description of Dwelling

All quotes are subject to brush verification.
Call us at 800-955-8213 for verification.

County

Occupancy type

Is this a mobile home?

Number of families

Building material

Protection Class

Does the home have a rolled flat or tin roof?

Year of Last Roof Replacement

Does the home have any knob or tube wiring?

Does the home have circuit breakers or fuse boxes?

Does the home have a wood or coal stove or heater,
or any other supplemental heating system?

Dwelling Value $

Year Built

Maximum Three Losses

Loss 1

Loss 2

Loss 3

Policy Information

Form

Vacant Coverage

Term

Coverage

Deductible

Liability

Liability Mold Coverage Buy Back

Medical Payments

Exclude Liability Coverage for Animal Injury?

Exclude All Coverage for Other Structures?

Other Structures $

Personal Property $

Personal Property Replacement?

Additional Living Expense $

Antenna / Satellite Dish Coverage $

Vandalism / Malious Mischief?

Earthquake?

Earthquake Other Structures?

Loss Assessment Coverage

Residence Burglary

Ocassional Rental?

Short Term Rental?

Exclude All Coverage for Roof?

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Underwriting Guidelines (PDF) Application (PDF) Supplemental Application (PDF)