Homeowers Quote Request


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Please send this information with attention to:

i. Contact Information: (* = required fields)

*Name
Date of Birth:
Spouse's Name:
*Home Phone:
*Address:
Business Phone:
*City:
Cell Phone:
*State:
   *Zip:
 

*Email Address:
*Confirmation of Email Address:

When is the best time to reach you? What is the best way to reach you?

ii. Prior Insurance Information:

Exactly when do you need your Homeowners Insurance?
Are you currently insured?
  If yes, then:
  Who is your Insurance Carrier?
  Approximately how much are you paying for your Homeowners Insurance coverage?

iii. Property Information: (if different from above)

Street Number:
Street Name:
Apartment Number:
City:
State:
 Zip:
Type of Residence:
Residence Use:
Square Footage:
Number of Stories:
Year Built: -- If during or before 1986, then please provide the year of updates to the building.
Wiring:
Plumbing:
Heating:
Roof:
Garage: Yes No -- If yes, for how many cars?
Carport: Yes No -- If yes, for how many cars?
Basement: Yes No -- If yes, approximate square footage? -- Is it finished: Yes No
Exterior: Brick Brick & Frame Other -- If other, what type is it?
Protective Devices: Dead Bold Locks Fire Extinguisher Smoke Detectors Central Fire/Burglar Alarm
Do you have any of the following?
  Dog -- If so, how many and what breeds?
Trampoline -- Does it have a safety net? Yes No

Pools -- Are they fenced in with a lock? Yes No

iv. Coverage Information :

Dwelling Coverage Amount: Liability Limits:
Deductible Amount:  
Medical Payments:  

v. Bells & Whistles:

Jewelry How much? Guns How much?
Computers How much? Fur How much?
Watches How much? Silverware How much?
Fine Art How much?    

vi. Other Coverages:

Are you interested in an Auto/Home or Renters discount that could save you up to 25% of your total insurance costs? Yes No

 

 

 
 
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