Homeowners Quote

To give you the lowest possible rate, it's important that we have your age (over / under 50) and the following information.

Information provided will be used exclusively for your insurance quote. It will not be given or sold to others or used for any other marketing purposes. We'll give you a quote and we'll leave you alone! 

PERSONAL INFORMATION:

Name:

Address:

Phone:

Email:

Contact me by... Phone    Email    Mail    Fax to:

Your age at time of renewal/purchase    Over 50    Under 50

Occupation: Retired     Other   

Have you had any claims in the last 5 years? No    Yes (explain)

Have you had any credit problems the last 7 years? No    Yes (explain)

HOME INFORMATION:

Year Built 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002     Stories: 1       1 1/2     2      2 1/2    Other

 Total Square Feet Screen / Patio Room    Yes      No     Size

Updated Plumbing?    Yes      No     Year     1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 Never

Updated Electrical?    Yes      No     Year 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 Never

Updated Roof?    Yes      No     Year 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 Never

Type of Roof    Comp Shingle Tile Wood Shake (not fireproofed) Wood Shake (fireproofed) Concrete Tile Metal Other     Purchase Price       Date

Garage Attached     Detached      None

Floor Coverings    Wall to Wall Carpeting Carpet over Hardwood Hardwood Sheet Vinyl Other

Construction Quality    Economy     Standard     Above     Custom

Miles from Fire Dept.         

Feet from Fire Hydrant        Less than 500'             More than 500' 

LENDER INFORMATION:

    Lender              

    Loan Number         Balance   

    Address   

    City        State        Zip   

    Flood Required? Yes    No    Not sure