Download PDFHomeowner Quote Questionnaire Step 1 of 3 0% Basic InformationName* First Last Spouse's Name First Last Date of Birth* MM slash DD slash YYYY Spouse's Date of Birth MM slash DD slash YYYY Occupation* Spouse's Occupation Home Phone*Cell Phone*Email Address* Best way to contact you Phone Email Phone or Email Have you or your spouse ever declared bankruptcy? Has any insurance company cancelled, non-renewed or refused to write a policy? If yes, please explain. Are there any lapses in coverage? Why? Current CoverageKnowing more about your current coverage helps us to provide a more accurate quote.Current Insurance Company Current Policy Number Expiration Date Month Day Year Current Annual PremiumProperty Coverage AmountDeductibleHave you made any homeowners claims in the last 5 years?If yes, please provide what type of claim, approximate amount paid out, and an approximate date.Do you require flood insurance? Yes No I'm not sure Do you require mine subsidence coverage? Yes No I'm not sure Do you require earthquake coverage? Yes No I'm not sure Do you have an alarm system? Yes, it's centrally monitored Yes but it's not monitored No Property Information Property Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Month/year property purchased Year house built Exterior Brick Brick Veneer Siding Number of Stories Square Footage Basement Yes No Percentage of Basement Finished Responding Fire Department Protection Class Distance to Nearest Fire Station Distance to Nearest Hydrant Would you like a quote on water/sewer back-up coverage? Yes - $5,000 Yes - $10,000 No Rooft Type Architectural Shingles Asphalt Singles Composition Year last replaced Year last repaired (if applicable)What year was the last update for:PlumbingHeating/ACElectricityCircuit BreakerAmperageNumber of Bedrooms Full Bathrooms Half Bathrooms Kitchen and Bathroom Customizations (Marble/granite, custom cabinetry, Jacuzzi tub, etc...)Floor CoveringsCarpet %Vinyl %Ceramic Tile %Hardwood %Laminate %Other %Number of Fireplaces Wood Burning Fireplaces Gas Fireplaces Wood Burning Stove or Furnace? Garage or Carport Garage Carport Neither Attached or Detached? Attached Detached Number of CarsPlease enter a number from 0 to 10.PorchSquare FootageCovered/Enclosed?MaterialsPatioSquare FootageCovered/Enclosed?MaterialsDeckSquare FootageCovered/Enclosed?MaterialsDo you have a pool?* No Yes, above-ground Yes, in-ground Is your pool locked/fenced?* Yes No Do you have a trampoline?* Yes, it's screened/locked Yes but it it's not screened or fenced No Pets (include any breed of dogs)Amount of jewelry/art/etc... to scheduleIs there a business on the property?* Yes No Please provide more information about the business* Are there more than five acres?* Yes No Is there farming on the acreage?* Yes No Describe any additional buildings on the premises Do you have any "umbrella" liability coverage? Yes No CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
