Home Insurance Quote Form
For the fastest and most accurate home insurance quote, please provide as much information possible in the form below. This information will be kept confidential and will be used for quote purposes ONLY!

General Information:

Social Security #:

First Name MI Last Name

Street Address
City St. Zip Code

Phone #:
Day Phone # Night Phone #
Best time to call

Email Address:

Safety Information:

Is your home located within 1000 feet of a fire hydrant? Yes No

Is your home located within 5 road miles of a responding fire station? Yes No

If your home is susceptible to flooding or high water, select the distance to the body of the water in feet.

If your house is built on a hill side, what is the slope?

Is your area prone to landslides and/or sinkholes? Yes No

How would you describe the road or street access to your home?

If a membership/fire tag is required for fire department response, is it current?

Your Home:

Number of families dwelling is designed for

Who lives in the dwelling?

What part of the year is the dwelling occupied?

Do you have any livestock or exotic pets? Yes No

About Your Dog(s)

Do you have a dog? Yes No

(If "Yes" is selected, please enter the following information.)


Check all that apply to your dog(s):
Over 50 Lbs.  
Bite History  
Obedience School  

Business on Premises

Is business conducted on the premises? Yes No

(If "Yes" is selected, please enter the following information.)

Type of business

Number of full-time employees

How many clients are seen per month?

Are there any visible signs or advertisements? Yes No

Does the dwelling look like a private residence? Yes No

Is there any special parking? Yes No

Loss History

Have you experienced any losses or claims within the last 5 years?
Yes No  

(If "Yes" is selected, please enter information on up to three losses within the last 5 years.)

Loss #1
Date of Loss:
Type of Loss:  
Amount of Loss: $

Loss #2
Date of Loss:
Type of Loss:  
Amount of Loss: $

Loss #3
Date of Loss:
Type of Loss: Other:
Amount of Loss: $

Home Construction

Total Living Area (approximate sq. ft.)  (Exclude porches, basements, decks, breezeways, and garages, but include built-in or basement garages).
Foundation Type
Garage Type
Open Porches
Enclosed Porches
Primary exterior wall type
Roof covering
Year Built (yyyy)
Number of stories

Home Style and Maintenance

Style of dwelling
How long ago was your roof replaced?
Plumbing system
How long ago was the plumbing in you house updated?
Was all of the plumbing in the interior of the home replaced? Yes No
What is your wiring type?
How long ago was your wiring updated?
Was the home completely rewired? Yes No
Which best describes your electrical service panel?

Key Features

Primary wall covering
Primary floor covering
How many fireplaces are in your home?
Heating and cooling system
What term best describes your kitchen?
# of full bathrooms
# of half bathrooms

Other Features

Do you have a swimming pool on the premises? Yes No

(If "Yes" is selected, please enter the following information.)

Does your pool have a diving board? Yes No
Is the pool used for swimming classes? Yes No
How high is the fence around your pool?

Do you have a wood, oil, or kerosene stove?
Yes No

(If "Yes" is selected, please enter the following information.)

What type of fuel does your stove use?
Is your stove listed/labeled by the Underwriters Laboratory or does it meet/test to a UL standard for stoves? Yes No
Who installed the stove?

Do you have a trampoline on the premises? Yes No

Optional Questions
Please note that if you choose not to answer these questions, 
you will not be eligible for any of these possible discounts

Burglar alarm type
Fire sprinkler system
Fire extinguishers Yes No
Smoke detectors Yes No
Fire alarm type
Deadbolt locks Yes No
Neighborhood Watch program Yes No
Gated community and security guard Yes No
Senior citizen discount (all occupants age 55 or above) Yes No
Smoke-free household Yes No

Your Coverage

Do you currently have insurance on this dwelling? Yes No
Desired Effective Date

Replacement Cost
This is the cost of rebuilding your home at today's prices. It is not the selling price nor the market value. It also does not include cost of the land or other structures on your property.

Replacement cost (You may want to use the amount listed under "Coverage A" on your current homeowner's policy.)
$ (This will be your Coverage A)

Coverage Preferences

Coverage A: Dwelling structure replacement (This is your replacement cost) $
Coverage B: Other structure replacement (Typical coverage limit: 10% of Coverage A) $
Coverage C: Contents or personal property (Typical coverage limit: 50% of Coverage A) $
Coverage D: Additional living expenses (Typical coverage limit: 20% of Coverage A) $
Personal Liability (Typical coverage limit: $300,000)
Medical Payments (Typical coverage limit: $5,000)
Policy Deductible
Business equipment coverage
Extended dwelling replacement cost coverage Yes No
Extended contents replacement coverage Yes No
Do you have any valuable possessions for which you would like to request additional coverage? Yes No

(If "Yes" is selected, please enter the following information.)

Jewelry $  
Furs $
Cameras (not used professionally) $
Musical Instruments (not used professionally) $
Silverware $
Golfer's Equipment $
Fine Arts $
Stamp Collections $
Rare and Current Coins $
Personal Computers and Electronic Equipment


Thank you for your time in submitting this Home Insurance
quote form. One of our representatives will respond to your
submission as soon as possible!