Homeowners Insurance Quote Personal Information Name * First Name Last Name Property Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone (###) ### #### Primary Policyholder's Birthdate Dwelling Information Year Home Built Home Square Footage New Home Construction? Yes No If Yes, Month/Year for Home to Be Complete Number of Units Single Family Duplex Type of Foundation Basement Slab Crawlspace Over Slab Other (Describe in Comments Below) If Basement, What % Is Finished? Type of Construction Frame Brick/Veneer Stone Other (Describe in Comments Below) Type of Roof Shingle Wood Shake Tar/Gravel Spanish Tile Metal Other (Describe in Comments Below) Number of Stories 1 1.5 2 3 Do You Own Animals or Pets? Yes No If Yes, List Type - For Dogs, List Breed Are You Near Brush Area? Yes No Number of Feet to Nearest Fire Hydrant Number of Miles to Nearest Fire Station Does the Home Have a Garage? Yes No If Yes - Detached/Attached? How Many Cars? Currently Insured? Yes No If Yes, Name of Carrier and How Long Insured? Prior Claims? Yes No Describe Claims in Detail Rate Your Credit History and Past Insurance Payment History Excellent Fair Poor Horrible Plumbing Type Copper Galvanized Mixed Heating Type Gas (Propane or Natural) Electric Electrical (If Oil, list tank location in comments below) Breakers Fuses Number of Bedrooms Number of Bathrooms Number of Fireplaces Number of Chimneys Special Features (Deck, A/C, Alarm Systems, Pool, etc.) Coverages Dwelling Coverage $ Content $ Liability Coverage $ Deductible ($250, $500, $1,000, etc) Comments Describe any scheduled jewelry, in-home business, oil tank location, or other special coverages/remarks here How would you like us to contact you? Email Phone Thank you!