Homeownwers Insurance Quote Request
For a request of homeowners insurance rates, please complete this form in its entirety. Should you submit the form and receive a message that a required field was not completed, use the back button on your browser to return to this form. The information submitted via this form is received directly by companies offering coverage in your area, and is confidential. If you have a policy currently, the information necessary to complete this form can be found on the declaration page. Fill in this form as complete as possible to ensure an accurate rate. If you are unsure of the correct answer to any of the fields, other than the required fields, skip them, but note in the comments section what you were unsure about.
Contact Information
First Name:
Last Name:
Date of Birth:	/ / mm / dd / yyyy
SSN:	(No Dashes)
Property Address:
City/State:
Zip Code:
Phone:
Best Time To Contact:	Morning Afternoon Evening
Fax:
E-mail Address:
Send Quotes via:	Phone E-Mail Fax
Covered Property Information
Are you currently insured:	Yes No
Type of Property:	Select One Single Family Town House Comdominium Duplex Fourplex Sixplex Apt.Complex Vacant Land
Occupancy (check all that apply):	Owner Occupied Rented to Others Second Home/ Vacation Rental
Number of Claims on any property owned in the last 36 months:	None 1 2 3 4 5 or more
Specific Information on the Home
Construction of Home:	Select One Wood Frame Brick/Masonry Concrete
Style of Home:	Select One Ranch Cape Split Level Colonial Raised Ranch Contemporary Row House (attached on either side) Town House
Number of Stories:	Select 1 1.5 2 2.5 3 3.5 4 or more (excluding basement)
What year was the home built:	(eg.2001)
What type of foundation supports the home:	Not Sure Concrete Slab Crawl Space Basement (finished) Basement (unfinished) Pilings
Roofing Material:	Asphalt or Architectural Shingles Clay or Spanish Tile Slate Wood Shake Concrete Tiles Don't know
Type of Heating:	Select One Oil Gas Electric Steam
Oil or Gas Burner replaced or updated recently:	Yes No
Electrical System: How many amps in electrical service?	Select One 120 220 Don't know
Garage Type:	Select One None Attached Built-in (rooms above) Detached
Number of cars garage holds:	None 1 2 3 4 or more
Security Features (check all that apply):	Smoke Detectors Fire Extinguishers Dead Bolts Local Burglar Alarm (rings outside home) Local Fire Alarm (rings outside home) Central Station Burglar Alarm Central Station Fire Alarm (Central station means connected directly to a monitoring facility that contacts police or fire dept on your behalf)
Home Features:
Central Air:	No Yes
Number of Bathrooms:	1 1.5 2 2.5 3 3.5 4 5 5.5 6
# Fireplaces:	None 1 2 3 4
Swimming Pool:	None Above Ground In-Ground
Insurance Coverage
What is the purchase price of the home:	$
Mortgage Amount:	$
Dwelling Amount: help
Personal Property Cov.:
Personal Liability Cov.: help	$100,000 $200,000 $300,000 $500,000 $1,000,000
Deductible: help	$100 $500 $1000 $1500 $2500
Is Earthquake Coverage Required:	Yes No
Do you need coverage for scheduled personal property (jewels, furs, silver) beyond what the standard policy offers? Usually big ticket items. help	Yes No
If yes, give amount in $'s for each:	Jewelry $ Furs     $ Silver   $ Other   $
Underwriting Questions
(as you may know, credit has become a major factor in obtaining insurance in a number of states, so please be aware that where applicable, rates will be quoted based on your responses below)
Filed For Bankruptcy in last 5 years?	Yes No
Your Credit Rating:	Good Excellent Fair Poor
Do you have pets?	Yes No
Other types of insurance you would like to see:	Auto Business Auto Flood Boat/Yacht
Do you Smoke?	Yes No
Comments:
Please press the submit button once