Home Insurance Signup Form - Egert&Cohen Insurance

General Information

First Name

Last Name

Date of Birth

ID or Passport Number

Spouse First Name

Spouse Last Name

Spouse Date of Birth

Spouse ID or Passport Number

Cellphone

Email Address

Street Address

Building No.

Apt No.

ZIP

City

Property Details

Do you own or are you renting?

Is the property used as a vacation/short term rental?

Is the apartment split into separate units?

Private house or apartment building?

What floor?

Total floors in the building?

Do you have a private garden?

Coverage Selection

Please select the type of coverage you want. You can choose either one or both. At least one must be selected.

Structure Insurance

Contents Insurance

Structure Insurance Details

How many meters?

Is the house renovated?

Do you have a mortgage?

If yes, which bank?

Market Value (in local currency)

Is the property occupied?

An unoccupied apartment is an apartment that is not lived in regularly for 60 days.

Do you have a pool?

If yes, approximate value of the pool

Contents Insurance Details

What type of front door?

Do you have Soragim (burglar bars) on the windows?

Do you have an alarm system?

Is the property occupied?

An unoccupied apartment is an apartment that is not lived in regularly for 60 days.

Is there a storage room to cover?

Do you need to insure contents in the storage room?

Do you have a safe?

If yes, contents value in the safe

Contents Value

Jewelry Value

Silver Value

Do you have garden furniture to cover (fire/lightning/explosion)?

Do you have a home-based business?

If yes, describe the business and if clients visit your house

Do you have a gun?

If yes, gun details Gun value

Do you have a swimming pool?

Final Disclosures

Have you been insured before?

Has any insurance company ever refused to issue a policy?

Has any insurance company ever refused to renew a policy?

Have you had any claims in the past 3 years?

If yes, please describe the claims

Have you had any criminal proceedings against you?

Review & Submit

Please review the information below. If everything looks correct, click Submit.

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