Chubb Customer Center Quote Request Form

Only agents enrolled in the Chubb Customer Center are authorized to use this form to request a quote. Please include your agency name and producer number prior to submission for a quote to be processed. If this information is not included or is not valid, the quote will not be processed.

Risks will be reviewed to ensure that they meet our target market guidelines and will not be quoted if they do not qualify. You will be notified if your risk does not qualify.
If you have any questions, please email: ccc-agent@chubb.com

   * means required field
* Agency Contact Name:  
* Producer Number:     Sub Producer Number (if known):    
* Producer Phone Number:     * Producer e-mail:  
* Customer Name:  
* DOB (mm/dd/yy):  
Customer Phone# (Home):     (Work)#:  
* Occupation:  
Job Title:  
Employer:  
If Retired List Prior Occupation:  
Spouse's Name:  
Spouse's DOB (mm/dd/yy):  
Spouse's Occupation:  
Spouse's Job Title:  
Spouse's Employer:  
If Retired List Prior Occupation:  
  
Present / Prior Carrier:  
Expiration Date (mm/dd/yy):  
* Has policy been non-renewed?     Yes      No 
* Has there been a lapse in coverage?      Yes      No 
If Yes to either, Why?  



HOMEOWNERS QUOTE SHEET

     Yes      No     
* Type of Dwelling:             Condo       House       Townhouse       Renters 
Risk-Address:  Primary Dwelling
Mailing Address (If different than Risk Location):
* Dwelling Limit / Additions and Alterations:         
If new purchase when will home be occupied?         
* Is the home currently under Renovation or Construction?      Yes      No 
* If NO, are there any plans for renovation or construction within the next twelve months?     Yes     No 
* Contents / Personal Property:  
* Liability:   * Deductible:  
Inservant:        Yes      No    (Hours worked 20 or more)
Outservant:      Yes      No    (Hours worked 10 or more)
Texas Deductibles
Wind and Hail - Choose either a flat or % deductible option
Flat Deductible:  
Percent Deductible:  
All Other Perils - Choose either a flat or % deductible option
Flat Deductible:  
Percent Deductible:  
* Is this the Primary Residence:      Yes      No 
* Is this a Secondary Residence:      Yes      No 

* Secondary Residence cannot be written without a qualifying primary home.
If Yes to Secondary, is it Rented to Others:      Yes      No 
* Total Square Footage:  
* Number of Stories:  
* Year Built (yyyy):  
If more than 30 yrs. or older please indicate any recent updates/upgrades to plumbing/electrical/roof /etc.

Special features of the home for calculation of the replacement cost?
Built in cabinetry?
Counter types?
Fixture types?
Customized or specialized rooms? (fitness center, home theater, etc.)

For California homes: If home was built before 1945, has it been retrofitted?      Yes      No 
Year the California home was retrofitted (yyyy):  
Construction Type:  
Distance To Brush (California):  
Roof Type:  
Roof Covering:  
Foundation Type:  
Basement Finished / Unfinished:  
PROTECTION: Homes must be within 1,000 feet of a fire hydrant and within 5 miles of a fire station to qualify for our preferred rates.
* Within 5 Miles From Fire Department:   Yes         No 
* Within 1,000 Feet From Hydrant:   Yes         No 
Texas Protection Classes 1 - 10    
* Burglar Alarm: Central Station  Yes         No 
* Fire Alarm: Central Station:   Yes         No 
Sprinkler System:   Yes         No 
Monitored Water Flow Alarm:   Yes         No 
Gated Community:   Yes         No 
Guarded Community:   Yes         No 
Distance From Water:   Cross Street:  
MORTGAGE INFORMATION:
* Is there a mortgage?   Yes         No 
* Will the mortgagee be the bill payor?   Yes         No 
Number of Mortgages listed on the policy:      

Mortgage Company Name and Address: 

Homeowner Loss History:
* Have there been any homeowner losses within the last 5 years?         Yes         No 

If yes, please provide full details of loss and mitigation against future loss:




VALUABLE ARTICLE QUOTE SHEET

Jewelry: # of Items:   Itemized Amt:   Blanket Amt:
In-Vault: # of Items:   Itemized Amt:   Blanket Amt:
Furs: # of Items:   Itemized Amt:   Blanket Amt:
Fine Arts: # of Items:   Itemized Amt:   Blanket Amt:
Collectibles: # of Items:   Itemized Amt:   Blanket Amt:
Silverware: # of Items:   Itemized Amt:   Blanket Amt:
Cameras: # of Items:   Itemized Amt:   Blanket Amt:
Other-Misc: # of Items:   Itemized Amt:   Blanket Amt:
In-Vault, please provide bank address below:
Valuable Article Loss History:
Have there been any valuable article losses within the last 5 years?        Yes         No 

If yes, please list valuable article loss information below: 




EXCESS LIABILITY QUOTE SHEET

Excess Liability Limit:   
If applicable: Underlying Automobile Liability Limits:  
# OF RESIDENCES:
Residence #1
Residence #2
Residence #3
Residence #4


If more than 4 residences, list in comment section at end of form

AUTOMOBILE QUOTE SHEET

     Yes      No
Does client have a Corporate Car?     Yes         No 


DRIVERS
* Driver Name * Date of Birth * License# * Vehicle #
1 
2 
3 
4 
5 
VEHICLES
* Year * Make * Model * VIN
1 
2 
3 
4 
5 
6 
7 
8 
9
10 

Accident, Violation, Loss History:
* Have there been any auto accidents, violations or losses within the last 5 years?     Yes         No 
If yes, please list all accidents, violations or loss information below:
NUMBER OF WATERCRAFT:
YEAR MAKE MODEL LENGTH HP/SPEED
 
Watercraft Accident, Violation, Loss History:
Have there been any watercraft accidents, violations or losses within the last 5 years?     Yes      No 

If yes, please list below:

If more than 4 watercraft, list in comment section at end of form

Comments:

  

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