Online Homeowners Quote Form

Fill out as much information as possible. If you are unsure about any of your answers, just submit the incomplete form and I will help you finish it ASAP!!!

***You must have Outlook, Outlook Express, or an e-mail program configured on your computer***

Name :

, head of household

E-Mail :

Home Telephone:

 - -
Work Telephone: - -

Cell Telephone :

- -

Address:

 

Age:

Form of Insurance:
Dwelling Information
Zip Code:

Year Built:

Square Feet:

Year Renovated:

Construction Type:

Roof Type:

# of Units:

(ex. if your condo is in a 50 unit complex, enter "50")

Outside City Limits:
Homeowner Loss History (past 5 years)

# of Claims Made:
Basic Discounts...Reduce My Premiums!!!

Non-Smoker:

Home Security:

Sprinkler System:

Central Burglar/Fire Alarm (ADT, Brinks, etc):

Local Electronic Burglar Alarm:

Local Fire/Smoke Alarm:

Home and Life Client:

Home and Auto Client:

Agree to Interior Inspection:
Replacement/Reconstruction Cost Information:

Estimated Replacement Cost:

# of Bathrooms? Grade?
Kitchen Grade?
Chimney? Type?

Pool? Fenced?

Deck?
Complete the fields in Blue if you don't know the reconstruction cost...

Estimated Market Value:
Interior Info:

Style Type:

Interior % Finished:

Interior Walls:

Interior Description:

Garage Type:

Kitchen Grade:

Basement % of Ground Floor:

Basement % Finished:

# of Fireplaces:

# of Garage Openers:

Air Conditioning:

Exterior Info:

Wood Shakes:

Asbestos Shingles:

Stucco on Frame:

Aluminum/Vinyl Siding:

Wood Siding:
Stone Veneer:
Solid Stone:
Paint on Masonry:
Stucco on Masonry:
Brick Veneer:
Solid Brick:

Adobe:

Bathroom Information

Standard Baths:

Luxury Baths:

Custom Baths:

Half Baths:
Porch/Breezeway Information

Breezeway Open:

Breezeway Screened:

Porch Open:

Porch Screened:

Deck:
Additional Feature Information

Jacuzzi:

Exterior Shutter:

Skylights:

Wet Bar:

Greenhouses:

Stained Glass:

Ornamental Stairs:

Laundry Tub:

Additional Furnace:

Screened Pool Enclosure:

Sauna:

Electric Air Cleaner:

Indoor Barbeque:

Trash Compactor:

Solar Panels:

Spiral Staircase:

Central Vacuum:

Intercom System:
Deductible and Liability Options

Personal Property:

Loss of Use:

 (living expenses during reconstruction)

Personal Liability:

Guest Medical:
 
Additional Comments: