Homeowner's Insurance Quote Request
James R Vozar Insurance Agency
Date
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Month
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Day
Year
Date
Time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Referred By:
Name
First Name
Last Name
SS#
DOB
Spouse Name
First Name
Last Name
SS#
DOB
Current Street Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Address of property to be insured
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number - (Home)
-
Area Code
Phone Number
Phone Number - (Work)
-
Area Code
Phone Number
Inside or Outside City Limits:
Inside
Outside
Responding Fire Department
Miles to Station
Brick or Frame:
Brick
Frame
Foundation
Slab
Crawl space
Basement
If basement is it finished?
Yes
No
Year Built
Square Feet
One Story or Two Story?
One Story
Two Story
# of Bedrooms
# of Bathrooms
Garage
Yes
No
Garage Attached or Detached
Attached
Detached
# of Cars
Central Air & Heat
Yes
No
Type of Heating
Fireplace
Yes
No
Wood-burning Stove
Yes
No
Are you smokers?
Yes
No
Number of Household Residents
Do you a home business?
Yes
No
If yes, what kind:
Coverages Requested:
Dwelling
Other Structure
Contents
Loss of Use
Liability
Medical Payments
Swimming Pool?
Yes
No
If yes, is it completely fenced?
Trampoline?
Yes
No
If yes, is it completely fenced?
Deductible Requested
Additional Comments:
Dead Bolt Locks
Yes
No
Smoke Alarms
Yes
No
Fire Extinguisher
Yes
No
Current Home Insurance Company
Any Claims filed in the past 3 years?
Any dogs? (How many and what types?)
Unusual Pets?
Any farming exposure?
Jewelry Scheduled
Guns Scheduled
All Terrain Vehicles
Motorcycles
Watercraft
Rental Houses
Updates to home: How complete?
Wiring
Plumbing
Roof
Central Air/Heat
Someone will need to come out to take a picture and inspect the home: What color is the home?
What are the driving directions:
Many of our insurance companies offer a discount when we insure both the home and auto, would you like a quote on your automobiles as well?
Yes
No
If yes, who is your auto insurance presently with?
We offer both life and disability insurance, would you be interested in a quote on either of these?
Yes
No
When would be the best time to come out to measure and look at the home? (No one needs to be home unless there is a wood-burner.) We need to do this before we can give you a quote.
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