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
Email
example@example.com
What company do you currently have homeowners insurance with?
What is the exterior material of your home?
Vinyl
Wood
Brick
Aluminum
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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