Homeowners Quote

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Step # 1 of 5 - Personal and contact information

COMPLETE SECTION # 1 - PERSONAL INFORMATION

Your contact information will be kept private and secure.

What is your name: *

Customer name or code:

Thanks for providing this information . If we need to contact you for additional information, we will send you a message through the secure Message Center. You can view a copy of this request, and a copy of your ID card, by clicking on My Transactions. You will receive an email confirming this request made on Monday, January 2, 2012 - 3:26pm. Your primary contact person in our office is .

By clicking the Submit Button you are agreeing to the Terms & Conditions of doing business with our agency via the Internet.
Click here to view the Terms & Conditions.

Home telephone number: *

Cell telephone number:

Work telephone number:

Email address:

What is the best way to contact you: *

When is the best time to contact you: *

S.S.N. (Optional):

Step # 2 of 5 - Current insurance information

COMPLETE STEP # 2 - CURRENT INSURANCE INFORMATION

Current insurance company: *

How long have you been insured with your current company: *

How long have you had this property continuously insured: *

Current policy expiration date: *

What is your current premium (optional):

Do you currently live, or plan on living, at this property in the next 12 months: *

How much coverage do you want on your residence: *

How much liability coverage do you want: *

What deductible do you want: *

Have there been any claims filed for this property in the past 5 years: *

Step # 3 of 5 - Property information

COMPLETE STEP # 3 - PROPERTY INFORMATION

City, State: *

Street Address: *

Zip code: *

Year built: *

Are there any loans on the property: *

Estimated square footage: *

Describe the type of property: *

Do you have a basement: *

How is the property used: *

What is the design of the property: *

Construction type: *

How many bedrooms: *

How many bathrooms: *

Type of roof: *

Type of electrical system: *

Type of dog (if any): *

Provide information on the following: *

	Yes	No	N/A	Unsure
Do you have a swimming pool?
Do you have a trampoline?
Do you have fire extinguishers?
Do you have deadbolt locks?
Do you have a fireplace?
Do you have a wood stove?
Do you have an uncovered patio/deck?
Do you have a covered patio/deck?
Do you have central A/C?
Does anyone in your household smoke?
Are you within the city limits?
Are you within 1000 feet of a fire hydrant?
Is the property within 5 miles of a full-time fire department?
Do you have any detached structure such as a garage, carport, cabana, guest house, etc?

Step # 4 of 5 - Protection Review

COMPLETE SECTION # 4 - PROTECTION REVIEW

In order to properly protect your assets, its important that we have complete information about your total account. Some of the questions determine if you are eligible for premium discounts.

When does your auto policy expire:

Who is your current company for auto insurance:

Provide information on the following:

	Yes	No
Do you have a vacation home?
Do you have rental property?
Do you have household members away at school?
Is the property prone to flooding or located in a designated flood plain?
Is business or farming conducted on the property?
Do you have any income-producing hobbies?
Do you have any art, guns or collectibles?
Do you have jewelry that you would want replaced if it were lost or stolen while on vacation?
If you sewer backed up and your carpet was ruined, would you want it replaced?
In the event of death, would you want the mortgage on your home paid off?
Do you have an inventory of your household possessions?
Would you prefer to lower your premium by choosing a higher deductible?
Do you have any recreational vehicles such as boats or snowmobiles?
Do you have coverage for Identity Theft Restoration?
If you were sued for $1,000,000 or more because you were at fault in an auto accident, or someone got hurt on your property, would you expect your insurance to pay?
If you had a chronic illness that left you unable to care for yourself for an extended period or time, do you expect to be covered by insurance?

Step # 5 of 5 - Comments and approval

COMPLETE SECTION # 5 - COMMENTS & APPROVAL

How did you hear about us: *

Credit history: *

Comments and questions (optional):

Enter a short description that you can use for future reference (Optional):

This description will display in the file cabinet which contains your complete transaction history.

By clicking yes below you agree to and accept the terms and conditions of doing business with this agency. Click here to view the terms and conditions.

I accept the terms and conditions: *

Yes

Please enter your initials to sign this quote: *

Customer name or code:

Thanks for providing this information . If we need to contact you for additional information, we will send you a message through the secure Message Center found in File Cabinet. You can view a copy of this request, and a copy of your ID card, by clicking on File Cabinet. You will receive an email confirming this request made on Monday, January 2, 2012 - 3:26pm. Your primary contact person in our office is .

By clicking the Submit Button you are agreeing to the Terms Conditions of doing business with our agency via the Internet.
Click here to view the Terms & Conditions.

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Homeowners Quote