Health Insurance Quote

~ Home Insurance Quote Request ~

ENTER INFORMATION BELOW
First Name		Last Name
Address		City
State	Zip code	Work Number
Home Number		D.O.B.
Spouse D.O.B.		Social security number
E-mail address		Do you currently Own your home, or Rent
Occupation		No. of Years
Employer
How would you prefer to be contacted? Phone Mail E-mail
To be contacted by phone, let us know the best time to call. AM PM
Claims(last 3 years)		Date	Amount Paid
Have you or any members of your household had a foreclosure, repossession, Bankruptcy, judgment or lien in the last 3 years? Yes No

STRUCTURAL INFORMATION
What is the style of your home?	How many stories is your home?
How many rooms do you have?	What is the total square footage of the living area of your home?

WHAT IS THE STRUCTURE OF THE FOLLOWING
Roof	Foundation	Garage
Most of the inside walls consist of		Exterior of your home
What is the replacement cost of your home:		Most flooring consists of

HOW MANY OF THE FOLLOWING DO YOU HAVE IN YOUR HOME
Full bathrooms	Half bathrooms	Fireplaces
Decks	Enclosed porches	Open porches

DO YOU HAVE THE FOLLOWING IN YOUR HOME
Dog? Yes No	Breed of Dog
Swimming pool? Yes No	Unusual/exotic pets? Yes No
Trampoline? Yes No	Computer? Yes No	Burglar alarm?
Kerosene, wood or oil stove? Yes No	Livestock? Yes No	Sprinkler system?

IS YOUR HOME LOCATED
Within 1000 feet from a fire hydrant? Yes No	Within 5 miles from the firestation? Yes No
On a hillside? Yes No	Close to a body of water or susceptible to flooding? Yes No

GENERAL QUESTIONS
Year home built	Number of families living in the home:
What part of the year is the home occupied?	Heating and cooling system:
What term best describes your kitchen?	Is business conducted on the premises? Yes No
Does anyone in your home smoke? Yes No	Did you experience any loss or claims in the last 5 years? Yes No
PROTECTIVE DEVICES
Smoke detectors? Yes No	Fire extinguishers? Yes No
Deadbolt locks? Yes	No Fire alarm?

ADDITIONAL INFORMATION
Gated community with a security guard Yes No	Neighborhood watch program Yes No
Senior citizen discount (all occupants age 55 or above): Yes No

HOME OWNERS COVERAGES AND DEDUCTIBLES
Dwelling $		Other structure $
Personal property/contents $		Loss of use of your home $
Personal liability $	Medical payments: $	Desired deductible: $