Homeowners Quote
Please complete the following form. Provide all of the information requested so that we will be able to get you the best rate.
Contact Information * indicates required field First Name * Last Name * Address City State Zip Phone Email Address * Home Description Type:
SELECT ONE
Dwelling
Condo
Rental
Owner Occupied?
Yes
No
Construction
Masonary
Frame
# of stories (exlcuding basement) Finished basement?
Yes
No
# of family units If more than 2 family units, is there lead paint?
Yes
No
N/A
Year purchased Copper pipes?
Yes
No
Heating Type
Gas
Oil
Electric
If the home is more than 20 years old , please indicate the month and year that each of following items has been updated. Plumbing (mm/yyyy) Heating (mm/yyyy) Electrical (mm/yyyy) Roof (mm/yyyy) Is your home withn 1500 feet of the ocean?
Yes
No
Please select all that are present and in the home. Smoke Detectors Fire Extinguishers Fire Alarm Sprinkler System Burglar Alarm Deadbolt Locks on Exterior Doors Coverage Limits Dwelling Coverage (not included with renter's insurance; )Rental or Condo Contents Coverage Amount (minimum limit $20,000) Would you like replacement cost coverage on contents?
Yes
No
Liability Coverage Amount
$100,000
$200,000
$300,000
$400,000
$500,000
Deductible
SELECT ONE
$250
$500
$1,000
$2,500
Please use the space provided below to list any items that you would like to have scheduled for an agreed amount. These items may include: jewelry, furs, silverware, etc. Make sure to list each item separately and the amount of coverage for each one. Other Information If you own autos, would you be interested in combining these autos with your homeowners or condo policy for additional discounts?
Yes
No
Have you had any homeowner claims within the last three (3) years?
Yes
No
If yes, please provide the date, claim-type and amount of the loss. Claim-type could include wind loss, water damage, fire loss, etc. Enter details below: Do you currently have insurance?
Yes
No
If yes, what is the current policy's expiration date? (mm/dd/yy) Is there any incidental office/business use in your home?
Yes
No
If yes, what type of business? Please use the space below for additional comments or questions. Keep this boxed check to receive updates on rate changes and new products.
