Homeowners Insurance Quote

First Name

Last Name

Street Address

City

State Select a state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

Date of Birth

Social Security #

Day Time Phone

Cell/Other Phone

Email

How would you like to be contacted? Select Type Phone Cell/Other Email U.S. Mail

Dwelling Information

1. What year was your home built?

Type of home? Select Type 1-Family 2-Family 3-Family

2. What style is your home?

3. What is the total square footage of the finished
living area of your home?

4. Does your home have a:

Deck Sq. Ft.

Cathedral Ceilings % of home

Breezeway Sq. Ft.
Is Breezeway: Select Enclosed Screened Open

Porch Sq. Ft.
Is Porch: Select Enclosed Screened Open

5. Which of the following additional features
are in your home?

6. Do you have a Garage?

Yes No

Type: Select Attached Built-in Carport Detached

How many vehicles can be parked in the garage? Select One Two Three Four

7. Does your home have a basement?

Yes No

If yes, percentage finished %

8. If your home does not have a full basement,
what percentage is:

9. Which materials listed below best describe the
materials found in your home? Please indicate the
materials as percentages of total
(e.g. 5%, 10%, 15%, etc.)

EXTERIOR WALLS:

INTERIOR WALLS:

WALL FINISHES:

ROOF COVER:

CEILINGS:

FLOOR COVERINGS:

10. How many kitchens are in your home?

Please indicate if any of your kitchens have
the following features:

11. Please indicate the number of bathrooms that are:

Full (3 or more fixtures w/ tub)

Half (sink, toilet, stand-up shower)

Half (sink/toilet only)

Please indicate quality: Select Standard Custom Designer

12. What is your homes primary source of heat?

Oil Gas Electric

Other

If you heat with oil, where is the storage tank located:

Do you have a secondary source of heat?

Yes No

If yes, please describe:

13. Does your home have central air conditioning?

Yes No

If yes, does it share ducts with the heating system?

Yes No

14. Does your home have a central vacuum system?

Yes No

15. How many fireplaces with masonry chimneys?

(DOUBLE is two fireboxes and one chimney,
TRIPLE is three fireboxes and one chimney)

16. Losses?
Yes No

dates:

How much paid out?

17. Detached Structures?

Yes No

If yes, what type of structure?

18. Animals or Exotic Pets?

Yes No

If yes, what type?

19. Trampoline?

Yes No

20. Pool?

Yes No

If yes, is it? Inground Above

Fenced? Yes No