Home Insurance Quote
Name
*
First Name
Last Name
Spouse Name
First Name
Last Name
Location Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (if different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
E-mail
*
How would you prefer to be contacted?
Phone
Email
If by phone, what's the best time to reach you?
Township
County
Type of home
House
Trailer
Modular
If it's modular, is it:
Titled
Deeded
HUD
Boca
Year home was built
Total square feet
Roof:
what year?
Electric:
what year?
Plumbing:
what year?
Furnace:
what year?
List all updates and additions and year completed
Number of stories
Type of basement
None
Crawlspace
Finished
Unfinished
If it's a trailer, is it on a permanent foundation?
Yes
No
List trailer make, model and serial number
Is the house?
Stone
Brick
Vinyl
Aluminum
Wood
Stucco
Is the roof?
Shingled
Tin
Cedar Shake
Clay Tile
Current Insurance Company
Liability limits
300
500
Current Deductible
250
500
750
1000
What is the value of the dwelling
List any claims in the last 5 years
How many household members are there?
Household Members
Owner #1's Occupation
Owner #2's Occupation
Does anyone in the house smoke?
Yes
No
Is there a trampoline?
Yes
No
Is there a pool, pond, or hot tub?
Yes
No
If yes, is it fenced?
Yes
No
Any of the following windows?
Bay
Bow
Picture
Any of the following doors?
Sliding Glass
French
Type of walls and ceilings (drywall, tongue and groove...)
Number of full bathrooms
Number of half bathrooms
Is there a garage?
Attached
Detached
No Garage
Size of garage
1 Car
2 Car
3 Car
Any other buildings on the property?
Are there smoke detectors?
Yes
No
Is there a central alarm system?
Yes
No
Is there a deck or patio?
Yes
No
Are there skylights?
Yes
No
Is there air-conditioning?
Yes
No
Is there a wood-stove / corn burner?
Yes
No
Is there a fireplace?
Yes
No
If yes to fireplace:
Chimney
Gas
List any pets or animals
List memberships to credit unions, alumni or other groups
How would you prefer to be contacted?
If contact is by phone, what is the best time to reach you?
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