HOMEOWNERS AND/OR LANDLORD INSURANCE QUOTE We would like to provide you with a free, no-obligation homeowners and/or landlord insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only. This form is hosted on a secure server using SSL technology.

 

Personal Information Primary Insured's Name (First, Last): Date of Birth: Primary Insured's Occupation: How long at current job: Highest level edu. completed Spouse's Name (First, Last): Date of Birth: Spouse's Occupation: How long at current job: Highest level edu. completed Property Location Address: City:   State:   Zip: Is the mailing address the same as the property location address? Y N Current Mailing Address: City:   State:   Zip: Day Phone:   Night Phone: Best Time To Call:   AM   PM Email Address:

How Did You Hear About Us? Please check all that apply: Search Engine Social Network Advertisement Family or Friend Forum/Blog Co-Worker Other:

Current Homeowners Insurance Information Company Name (not agency): Policy Expiration Date: Amount Insured For: $  Policy Type: Primary Seasonal Rental  Has property insurance been cancelled, declined or non-renewed in last 5 years?  Y   N Number of losses incurred in the last 5 years to the insured's  home or personal possessions at this or another location:  Desired Deductible: $

Home Information Is home under construction?: Y N     Year Home Was Built: Dwelling Status: Owner Occupied/Primary Owner Occupied/Secondary Vacant Rented to Others   How Long: Date of ownership: (mm/yy)     Purchase Price: $ Sq. Footage (excl. garage and basement): sq. ft.         # of Mortgages:

Home Usage Children under the age of 18 living in the home?: Y N Any smokers living in the home?: Y N Is there a business on the premises?: Y N In-home daycare on the premises?: Y N Dogs on premises of following breeds?: Y N      American Bulldog Akita Chow Doberman German Shepherd Great Dane       Pitbull Presa Canarious Rottweiler Staffordshire Bull Terrier Wolf Hybrid or mix of any of these Horses and/or livestock kept on premises?: Y N Is there a wood burning stove?: Y N

Structure Information Type Construction Roof Foundation Garage 1 Story 1 1/2 Story 2 Story Split Level Bi-Level Townhouse End Unit Townhouse Interior Unit Other Frame Stucco Vinyl Siding Brick Veneer Masonry Other Asphalt Shingle Wood Shingle Tile or Slate Other Basement Crawl Space Slab Other 1 Car 2 Car 3 Car 4 Car None Age of roof: yrs. Attached Detached Basement Built-in Car Port None

Features Bathrooms Basement Deck/Porch/Patio Sq. Feet Fireplaces # of Full:   # of Half:   None Finished Unfinished   Sq. Ft.:   Deck:   Porch:   Screened Patio:   # of Chimneys:   # of Fireplaces:

Additional Features Primary Heating System Age of Heating Age of Electrical Fire Sprinkler System? Gas/Propane Hot Water Gas/Propane Forced Air Electric/Gas Heat Pump Electric Forced Air/Baseboard Yes Central Air Sump Pump Security Alarm Fire Alarm Smoke Detector Yes Yes None Monitored Not Monitored None Monitored Not Monitored Yes

Additional Comments Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter them here.

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