Name: Tom Needham Insurance Agency
Address: 3411 W. Wendover Avenue, Suite A, Greensboro, NC, 27407
Telephone: (336) 855-1223

Proposed effective date ?*
DD slash MM slash YYYY
Full Name*
Telephone*
Email Address*
Address
Is this new purchase ?
Years at address above
Prior Address if less than 6 months at address above
Number of Residents
Insured Information
Full Name of Occupant #1
D.O.B
DD slash MM slash YYYY
Social Security #
Full Name of Occupant #2
D.O.B
DD slash MM slash YYYY
Social Security #
Full Name of Occupant #3
D.O.B
DD slash MM slash YYYY
Full Name of Occupant #4
D.O.B
DD slash MM slash YYYY
Do you currently have property insurance?
- Yes I currently have insurance
- No - choose reason below
Current Carrier Name
Policy Effective Date
Reason for No Prior Insurance
Dwelling Amount
Other Structures Amount
Personal Property Amount
Liability Coverage Requested
Guest Medical Liability
* Note Many other coverages such as "loss of use" are % based on Dwelling amount. Please list any special or unusual limits needed.
Type in any misc. coverages:
Does dwelling have any of the following built-ins? (If yes, write in number)
Through-the-wall unit air conditioner
Air humidifier
Bathroom heater
Ceiling fan
Central vacuum system
Countertop range
Dishwasher
Domestic solar hot water heater
Built-in dryer
Electronic air filter
Garage door opener
Garbage disposal
Heat exchanger
Hot tub
Intercom system
Interior sprinkler
Bit-in Microwave
Bit-in oven
Prefab Fireplaces
Range Hood
BIt-in refrig
Roof Exhaust fan
Sauna
Secur/Fire Alarm
Skylight
Smoke alarm
Trash compactor
Video door ans
Bit-in washer
Water purif sys
Water softener
Wet bar
Whirlpool tub
Whole-house fan
Wood middle Stove
Safety Items
- Central Station Burglar Alarm
- Central Station Fire Alarm
- Both Central Station Fire & Burglar Alarm
- Smoke Detectors
- Dead Bolt Locks
- Fire Extinguisher
- Fire Sprinkler Sys.
Loses
Furnish Dates & Description of any Losses
UPDATES
Plumbing
Year
Electrical
Year
Total Amperage
Heating/Cooling
Year
HVAC - Type
Roof
Year
Roof Type
HAZARD
Please list any unrepaired damages and incomplete projects
Trampoline
Swimming Pool
Pets
Please list number and breed of all pets
Additional information, instructions, or comments.
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