Your full name (include middle name):   

Your Birthdate:

Your Social Security Number  Note: Several companies give a discount that depends on credit rating. It can be as much as a 75% difference in premium!  Thus, a credit report will be ordered to determine if you are eligible for a discount.  If you are adamant about NOT wanting to have a credit report search, then please state so in the comments at the end of this form prior to submitting.  You will not be eligible for the discount in this case and your quote will likely be higher than otherwise:

Spouses full name (include middle name)

Spouses Birthdate:

Your email address:           
Your home phone number:          
Your work phone number:           

Full Property Address: 

Street:

City      State   Zip

County (not Country):    Responding Fire Dept:
Miles from Fire Dept:
Is there a fire hydrant within 1,000 feet Y or N?

Your CURRENT full mailing address if different from Property (or put "same"):

Street: 

City         State   Zip

 Birthdate of oldest member of household?
Your occupation & employer:          
Your spouse's occupation & employer:
   
What Coverage Limit do you have or want on the dwelling?:      

_________________________________________________________________________________.
Deductible(Click to highlight deductible wanted):                 $250 $500 $1,000

_________________________________________________________________________________
Liability Limit (Click to highlight limit wanted):   $100,000 $300,000 $500,000 $1,000,000 Guest Medical Payment Limit: $1,000 $5,000

__________________________________________________________________________________

Approx Sq Ft of your house:               
Frame or Brick?:                                 
If Brick, what percentage is brick?:      
Year your house was built:                   
Age of roof (Enter the Year):               
Age of furnace(Enter the Year):           
Age/Condition of plumbing (Enter latest update year & describe)   
Age/Condition of wiring (Enter latest update year & describe)        
Who will be/is living in the house?        
List all pets owned or put "none". If dog(s), please list breed

Homeowners policies from most companies exclude damage  from any type of water in the home including backup of water through sewer, sump pumps or drains.  Some companies let you add additional coverage to add limited coverage for backup of sewer, sump pump or drains.

Are you concerned about this? No-don't care    Yes, I want coverageMaybe-depends on cost.

Do you own now, or do you plan to get a satelite dish?:No    Yes

Please describe any and all claims you have had in the last 5 years on a homeowners or renters policy--even if it was a different home. Include amount of claim and approx date. If none, then type in "none":

If you recently purchased the home, please enter the price paid and year purchased:
If you are just now buying the home, what is the closing date?:  

Multi Listing Number (MLS#) from Realtor Listing if applicable:

Does ANYONE in the household smoke?:
How Many Smoke detectors do you have?:
Do you have at least one fire extinguisher?:  
Do you have deadbolt locks on ALL doors leading outside?
Do you have an alarm system?
    If you answered yes to alarm system, please describe how it works and whether it makes noise, notifies a central station etc. 

Do you have a wood burner?:                    (fireplace is NOT a woodburner)
If  you are a  member of any group (such as AARP, alumni association, etc.) what?:

Your Current Insurance Agent                 
Current Insurance Company:                   
Policy Number:                                      
Annual Premium you are paying currently:
Expiration date of current policy:             

Is your current company canceling or non-renewing you?  If so, Why?
What company currently insures your AUTOs?:  

Do you want a Quote for Mortgage Life Insurance to pay off the mortgage is something were to happen?

If so, Enter the amount of your mortgage and the number of years it is amortizing over

.

Coverage Notes: In addition to the dwelling limit and liability limit, our quotes will typically include:

Other Structures at 10% of the dwelling limit

Personal Property at 70% of the dwelling limit

Loss of Use at 20% of the dwelling amount or one year

Personal Property Replacement Cost

Extra comments (you  can keep going past the end of the line):

Did you fill in all the information?  Did you have your existing policy in front of you to ensure an "apples-to-apples" quote?  

How did you find our site?  Yahoo Other Search Engine I have other insurance with you Referral From a Friend/Relative Radio Ad Television Ad Received Info In Mail Ad in Wall St. Journal Other

If you chose "Other Search Engine, which one? or if you chose "Other", What?

Thank you for completing our online quote form. Please let us know how you would like us to send you the quote:

 Phone Call     Fax  

If you entered "phone call" and we call at night, how late can we call you?

If you entered "Fax", what is your fax number: