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Homeowners/Renters Insurance
Quote
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| Date: |
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| How did
you hear about us? |
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| Name: |
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| Phone
number: |
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| Best time
to call you back? |
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| Can we
leave a message on machine? |
Yes
No |
| Address:* |
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| City:* |
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| State:* |
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| Zip Code:* |
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| Is dwelling
located within city limits? |
Yes
No |
| If "No",
how many miles is dwelling located from the answering fire department? |
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| Year dwelling
was built: |
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| Do you
currently have insurance on this dwelling? |
Yes
No |
| If "Yes",
which company is it insured with? |
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The reason for this question is that since we
are an independent agent, you may have insurance with one of the
companies we represent. This will prevent us from quoting the
same company.
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| Deductible
Options: |
$100
$250
$500
$1,000 |
| Construction
type: |
Frame (wood)
Brick |
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Amount of Insurance
on:
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Dwelling:
(Does not apply to renters) |
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Personal
Property:
(Usually 50%-75% of dwelling, depends
on policy) |
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Additional
Living Expense:
(20% of dwelling amount is included) |
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Other
Structures:
(10% of dwelling amount is included) |
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| Liability
to the Public: |
$100,000
$300,000
$500,000
$1,000,000 |
| List any
renovations and year performed: |
Wiring
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Plumbing
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Heating
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Roofing
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Exterior Paint
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| What losses,
either property or liability, have there been in the past 3 years? |
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Do you have/want replacement cost coverage on:
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| Dwelling? |
Yes
No |
| Personal
Property? |
Yes
No |
| Do you
have anything that requires specific insurance (i.e. jewelry, guns,
antiques)? |
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| Is there
any other pertinent information regarding this house or location? |
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* Denotes a required field.
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This is basic information we need to get you a
price. There are other questions on an application that may affect
the premium.
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