Medler Insurance Agency_01-0518-00

Home Insurance Quote Request

Medler Insurance Agency
Name

First Name Last Name
Phone Number

Area Code Phone Number

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Email
example@example.com
What company do you currently have homeowners insurance with?
What is the exterior material of your home?
How many stories is your home?
What is the square footage of your home above ground?
What year was your home built?
Do you have a basement or a crawlspace?

Yes No
If yes, how much of your basement is finished?
Is it a walkout?

Yes No
How many full bathrooms?
How many half bathrooms?
How many car garage?
Is it attached or unattached?
Do you have any out buildings?

Yes No
If yes, what are the dimensions?
Do you have any decks or porches?

Yes No
If yes, are they in the front or back of the house?
Do you have central air?

Yes No
Do you have a fireplace?

Yes No
Do you have a wood burning stove?

Yes No
If yes, what is the age?
Is it man-made?
Do you have a local or central station alarm?
Do you have any animals?

Yes No
If yes, how many?
What type and breed?
Do you have a trampoline?

Yes No
Is there a fence around it?

Yes No
Do you have a pool?

Yes No
Is it above ground?

Yes No
How deep is it?
Does it have a diving board?

Yes No
Does it have a slide?

Yes No
Is there a fence around it?

Yes No
Do you have any boats?

Yes No
If yes, what is the year, make, and model:
Do you have any recreational vehicles?

Yes No
If yes, specify what they are:
Is there any type of business conducted from the premises? (Such as a daycare or a hairdresser.)

Yes No
If yes, what is it?
Do you currently schedule any property? (Guns, antiques, jewelry, or furs)

Yes No
If yes, what are the values?
What is the age of your roof?
Have you had any electrical or plumbing updates?
Is your furnace gas, propane, oil, or electric?
Have you had any homeowners claims within the last 3 years?

Yes No
If yes, what were they for?
How much did the insurance company pay for the claim?
Do you currently have an auto policy with another company?

Yes No
If yes, what is the name of the company?
DISCOUNTS
What is the date of birth of the oldest person in your household?
Are you a member of any alumni?

Yes No
If yes, what is the name?
Are you a member of a credit union?

Yes No
If yes, what is the name?
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Home Insurance Quote Request