We support our troops!

 

 

 

 

helpful hints

Homeowners Insurance Quote Form

Before you proceed, please allow me to explain our quote process.  Based on your profile you will be provided with quotes from national insurance companies. These companies respond to your request according to your preference: by Mail, FAX, E-Mail, or Phone. We ask for as much information as possible to get you the most accurate quote possible. Take note that most major companies now check your credit history, claims history, driving record and can also be aware of other applications submitted to different companies (only for life insurance). Whatever information is out there, it will probably be found. Be honest, so the companies can be accurate.

You are under no obligation to purchase insurance and all information you provide is strictly used for the purpose of providing you with quotes.  We are purposely not asking for social security numbers, but you will almost definitely need to provide those when you make application for your coverage

CONTACT INFORMATION

Name
E-mail Address
Home Phone Number
Work Phone Number
Cell Phone Number
Fax Number
Address
City
State
Zip
County

 

SAFETY FEATURES

Within 1000' of fire hydrant YES    NO 
Within 5 miles of fire station YES    NO 
Fire Extinguisher YES    NO 
Home Fire Sprinkler System on each floor YES    NO 
Smoke Detectors on each floor YES    NO 
Fire Alarm which responds to a central station (monitored) YES    NO 
Deadbolt locks on all exterior doors YES    NO 
Burglar Alarm which responds to a central station (monitored) YES    NO 
24 hour manned security service YES    NO 
Home located on a paved road YES    NO 

 

PROPERTY INFORMATION

Current Market Value of Property
What was/is your purchase price? 
Dog owner? YES    NO 
Dog Breed #1
Dog Breed #2
Dog Breed #3
Time Occupied
Business on property? YES    NO
Are you a first time home buyer? YES    NO
Year Built
Style of Dwelling
Type of Dwelling
Air Conditioned/Heated Square Feet
Type of Construction
Attached Carport
Unattached Carport 
Attached Garage 
Unattached Garage
Basement
Roof Type
Wood Deck
Wood Stove or Fire Place 
How many bedrooms?   
How many baths? 
Tennis Court ? YES    NO 
In Ground Pool? YES    NO 
Screen Enclosure?

 

Coverage & Deductible

Deductible
Hurricane Deductible
Personal Liability
Approximate Replacement Cost of Dwelling
Medical Payments
Would you like a quote on mortgage protection? YES     NO  
Would you like a quote on life insurance? YES     NO  
Do you have current property insurance? YES     NO  
Current Insurance Company 
Current Policy Number
Date to start new insurance Mth     Day    Yr 
If new purchase, what is your closing date? Mth     Day    Yr 

 

Loss History

Losses over last 5 years  

Type 
Amount paid by insurance company

Type 
Amount paid by insurance company 

Type   
Amount paid by insurance company 

Type 
Amount paid by insurance company 

Type 
Amount paid by insurance company 


Additional Comments

     

How were you referred to our website?

Search Engine 

Which Search Engine?
Excite    MSN    Altavista     CNN     Google                                                Other 

Superpages.com 

RealPages.com 

Told about by Realtor 

Told about by Mortgage Company 

Yellow page ad 
If so which one
 

Link from another site 

When you have finished filling out the form and are sure all the information is correct, please click SUBMIT.  Check your information carefully as you will not be able to use the RESET button and change any information after you have selected SUBMIT.

If you find an error and would like to make a change please use the BACK button on your browser.

If you need homeowners coverage immediately, please call 1-877-966-0364 or 407-281-6300.