Customer Information
First Name:
Last Name:
Street Address:
City:
State:
Alabama
Alaska
Arizona
California
Colorado
Conneticut
Deleware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
Day-Time Phone:
Cell/Other Phone:
Email Address:
Current Residential Status:
Please Select
Own
Rent
Live with Parents
on campus
Current Homeowners Insurance Information
Do you currently have homeowners insurance?
Please Select
Yes
No
Company Name:
Policy Expiration:
Premium Amount:
Amount Insured for:
Home Information
Primary or Secondary residence
Primary
Secondary
How Long at Present Address:
Estimate Year of Construction:
What type of home is it?
Single Family
Multi Family
Apartment Complex
-----------
Other
Do you conduct business in home?
Yes
No
Sq. Footage:
# of Claims In Last 3 Years:
Amount of insurance needed (approx $ amt - ie $200,000)
How much liability insurance?
$ 100,000
$ 300,000
$ 500,000
$ 1,000,000
-------
Other
Deductible:
Please Select
$ 250
$ 500
$ 1,000
$ 2,500
----
Other
Structure Information
Home Type: Construction: Roof: Foundation:
Garage size:
Please Select
1 Story
1 1/2 Story
2 Story
Split Level
Bi-Level
-----
Other
Please Select
Frame
Stucco
Vaneer
Masonry
-----
Other
Please Select
Asphalt Shingles
Wood Shingles
Tile or Slate
-----
Other
Please Select
Basement
Crawl Space
Slab
-----
Other
Please Select
Attached
Detached
None
Please Select
1 Car
1 1/2 Cars
2 Cars
2 1/2 Cars
3 Cars
3 1/2 Casr
4 or More Cars
Age of Roof:
Features
Bathrooms Deck/Porch/Patio Fireplaces
# of Full: Deck Sq. Ft: Wood or Pellet Stove:
# of Half: Porch Sq. Ft: Fireplaces:
Screened Patio Sq. Ft:
Central Air: Central Vac: Security Alarm: Sprinklers:
Smoke Detector:
Yes
No
Yes
No
Monitored
Non Monitored
None
Yes
No
Yes
No
Swimming Pool: Diving Board: Trampoline: Service Panel Type:
Yes
No
Yes
No
Yes
No
Circuit Breaker
Fuse Box
Unknown
------
Other
Additional Features
Do you own any pets? (how many?)
Marital Status
Single
Married
Separated
Divorced
Widowed
How would you describe your credit rating?
Poor
Good
Excellent
Unknown
Please list any jewelry or specialty items(i.e.) engagement ring
What else can we help you with?
Do you need Auto Insurance?(Additional discounts may apply):
Please Select
Yes
No
Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have additional where there was not enough space, please enter them here.
Continue