Homeowners Insurance Quote Request

Homeowners Insurance Quote Request
- Full Name
  
  First NameLast Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Phone Number
  
  Area CodePhone Number
- Fax Number
  
  Area CodePhone Number
- E-mail
- Birth Date (For Discount Purposes)
  
  MonthDayYear
- How would you rate your credit?
- Property's Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Mortgage Balance:
- What is the market value of your home?
- Number of Families:
- What is the dwelling type?
- Number of bedrooms:
- Number of bathrooms:
- Number of fireplaces:
- Number of porches/decks:
- What year was the property built?
- What date was the property purchased?
- What is the construction type?
- How many stories?
- If two stories, what is the ground floor square footage?
- What is the total square footage of the building?
- What is the property's typography?
- What foundation type?
- If structure is located in a flood zone, what is the distance to body of water?
- What type of garage?
- What type of roof covering?
- Was the roof updated?
- If YES, what year?
- Does the building have a pool?
- If there is a pool, is it fenced?
- If there is a pool, is there a lockable fence?
- If there is a pool, is there a diving board?
- If there is a pool, is there a slide?
- What is the distance of fire protection?
- Is the building in the brush?
- Is there a brush hazard within one mile of the building?
- If YES, has a brush been cleared by 250 feet from all sides of the building?
- Is there a smoke alarm?
- Is there a fire extinguisher?
- Are there deadbolts?
- Is the electrical updated?
- Are there circuit breakers?
- Does the circuit box have copper wiring?
- Do you have central air?
- How old is the heating / air conditioning?
- Is the heating / air conditioning thermostatically controlled?
- What is the energy source?
- What is the cooling system?
- Has the plumbing is updated?
- Is the plumbing copper?
- Does the building have interior automatic fire sprinklers?
- Is there a theft alarm?
- Is there a fire alarm?
- Are the alarms monitored?
- What is the earthquake zone?
- Has it been earthquake retrofitted?
- What is the fire district?
- Do you have a trampoline?
- Number of acres dwelling is located on?
- Are there dogs on the property?
- If YES, how many and what is the breed of each dog?
- Are there any other pets or animals in the property?
- If YES, how many and what is the description of each?
- What is your current insurance company?
- Expiration Date
- Where there any losses or claims in the last 5 years?
- If YES, what is the date, amount paid and description of each loss or claim?
- Dwelling Amount (Coverage A)
- Other Structures (Coverage B)
- Personal Property (Coverage C)
- Loss of Use (Coverage D)
- Premise Liability
- Policy Deductible
- If earthquake insurance is requested, select deductible percentage?
- Do you want building replacement cost coverage?
- Do you want contents replacement cost coverage?
- Further questions or comments?
- IF YOU HAVE MORE THAN 1 RESIDENCE, PLEASE FILL OUT ANOTHER FORM.
  
  Please Note: Insurance coverage cannot be bound without a written binder from our office.
  
  Please Also Note: Many insuranec carriers use information gathered from you and outside sources about your claim, credit history and home. This information allows insurance companies to determine accurately the proper price to charge. You are entitled to a free copy of the reports by contacting the appropiate consumer reporting agency within the next 60 days.
  
  By filling out this form, you agree to the above terms.
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