Home Quote Form
(Not for Mobile Homes, Park Models, or Manufactured Homes)
Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Middle Initial
Last Name
Suffix
Date of birth (MM/DD/YEAR)
*
Social Security Number (Not required, but providing it may improve your financial rating for quoting)
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Occupation
*
Highest level of education or military:
*
Marital Status
*
Single
Married
Separated
Divorced
Widowed
Domestic Partnership
Co-Insured (Spouse, Significant Other)
*
First Name
Middle Name
Last Name
Suffix
Date of birth (MM/DD/YEAR)
*
Occupation
*
Highest level of education or military:
*
Does this person reside in the home?
*
Is there anyone on the deed besides yourself?
*
Yes
No
List all names listed on the deed and their relation to you:
Is your home deeded to trust or business?
*
Yes
No
Please explain:
*
Is there anyone in the home BESIDES yourself, spouse, or children?
*
No
Yes
Please list ADDITIONAL household members:
Location Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Is your home located in a Township?
*
Township
*
County
*
Do you have a mortgage on the property?
*
YES
NO
Land Contract
Who is your mortgage with?
*
Who is the land contract with?
Mailing Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Is the Mailing Address the same as the property location?
*
Yes
No
How did you hear about us?
*
Google
Facebook
Referral
Advertisement
Current agent/company
Current Client
Other
What type of property is this?
*
Owner-Occupied Single-Family Home
Owner-Occupied Multi-Family Home
Non-Owner Occupied Single-Family Rental
Non-Owner Occupied Multi-Family Rental (up to 4 units)
Owner-Occupied Condo (Excluding Exterior)
Owner-Occupied Condo (Including Exterior)
Non-Owner Occupied Condo Rental (Excluding Exterior)
Non-Owner Occupied Condo Rental (Including Exterior)
Owner Occupied Farm (No Farm Exposure)
Owner Occupied Farm (Farming Exposure)
Non-Owner Occupied Farm
Other
Does your Condo Association have a policy to cover the exterior of the building?
Yes
No
How many total units in building?
*
One
Two
Three
Four
Other
Is the property currently vacant?
*
Yes
No
Back
Next
Please provide detail as to why the property is vacant and the anticipated length of time it will remain vacant:
*
Is this a new purchase?
*
Yes
No
Purchase date of property
*
Purchase Price
*
Current market value of home
Number of Acres
*
Responding fire department
*
Miles to fire department
*
1-3 Miles
4-6 Miles
6-9 Miles
Over 10 Miles
Are you close to any alternative water sources (river, stream, lake, etc.)
*
Please indicate if there are any animals on the property (Number, type, breed, and if there has been any bite history)
*
Do you own or operate a business out of your home? If so, please explain:
*
Back
Next
Year home was built
*
Number of Stories
*
1
2
3
Bi-Level
Tri-Level
Other
Square footage above grade (DO NOT INCLUDE FINISHED BASEMENT OR ATTIC)
*
Construction type:
*
Frame
Brick on Frame
Stone on Frame
Stucco on Fram
Masonary
Modular
Other
Foundation material
*
Concrete
Cement Block
Limestone
Other
Foundation Shape
*
Rectangle
L Shape
U Shape
Other
Foundation type (If it is a mix of two or more, select "Other":
*
Slab
Unfinished Basement
Finished Basement
Partially Finished Basement
Crawl Space
Other
What is the square footage of the FINISHED basement area?
*
Quality of construction
*
Basic
Standard
Custom
Above Average
Do you have a garage?
*
Yes - Attached
Yes - Detached
Yes- Attached Carport Only
No
What are the number of garage stalls:
*
Do you have any other detached structures? (Fencing, shed, pole shed, gazebo, etc.)
*
Yes
No
What is the year, construction type, siding type, roof type, square footage, and value of detached structure(s)? (Example: Detached garage, built 1997, Frame, vinyl siding, asphalt shingle roof, 682ft, value $25k)
*
Do you have any of these ATTACHED structures?
*
Deck
Open Porch
Enclosed Porch
Breezway
Balcony
Other
NONE (or cement or block patio)
Dimensions/square footage of attached deck:
*
Dimensions/square footage of attached porch:
*
Dimensions/square footage of attached enclosed porch:
*
Dimensions/square footage of attached breezeway:
*
Dimensions/square footage of attached balcony:
*
Dimensions/square footage and description of attached structure:
*
Siding Type
*
Vinyl
Aluminum/Metal
Wood
Stucco
Other
Age of siding:
*
Is there any stone or brick in addition to the siding type selected above? Please explain what type of material and percentage of total exterior it covers.
*
Back
Next
Number of bedrooms:
*
Number of full bathrooms (toilet and bathtub)
*
Number of 3/4 bathrooms (toilet and shower)
*
Number of 1/4 bathrooms (toilet)
*
What is the material of your interior walls?
*
Drywall
Plaster
Other
What type of flooring is in your home (select all that apply)?
*
Carpet
Laminate
Vinyl
Hardwood
Marble Tile
Ceramic Tile
Other
Please indicate the percentage of each flooring type indicated above. (Example: carpet- 50%, ceramic tile 25%, hardwood 25%. Also, if you selected "Other" above, please explain below.
*
Do you have central air?
*
Yes
No
Age of central air?
*
Do you have a water softener?
*
Yes
No
Age of water softener
*
Do you have a fireplace or wood stove?
*
Yes - Gas fireplace
Yes- wood burning fireplace
Yes - wood stove in home
Yes - wood stove outside of home
Yes - wood stove in an outbuilding or garage
NONE
Other
Is your wood stove UL listed and professionally installed?
*
Please indicate exact location of specifics of wood stove:
*
Do you have any of the following in your home? You can select multiple options.
*
Whirlpool tub
Large walk-in shower
Sauna
Wet bar
Stained glass
Built in bookcases
Window seats
Bay window
Bow Window
Arched doorway
Elaborate woodwork
Crown molding
Skylights
NONE
Other
Please describe (if applicable) any other customized features:
Do you have a trampoline?
*
Yes - netted & fenced
Yes- not netted & fenced
Yes - netted & not fenced
Yes - not netted & not fenced
No
Do you have a pool or hot tub?
*
Yes
No
Please indicate depth, if there is a diving board or slide, and if there is a locking gate/cover present and if it is a fenced-in yard
*
Please select all that apply:
*
Smoke detectors battery
Smoke detectors hard wired
Carbon monoxide battery
Carbon monoxide hard wired
Dead bolt locks
Centralized alarm system
Ring doorbell
Surveillance cameras
Fire extinguisher
Sprinkler system
Back
Next
Type of roof on home
*
Please Select
3-tab asphalt
Architectural shingle
Metal
Rubber
Other
Age of roof
*
Type of plumbing
*
Please Select
Copper
PEX/PVC
Galvanized
Combination of PVC & Copper
Age of plumbing
*
Type of heating
*
Please Select
Furnace - Gas
Boiler
Solar
Electric baseboard
Age of heating
*
Type of electrical service
*
Please Select
Breakers
Fuses
Age of electrical
*
Do you have ANY knob and tube wiring?
*
Yes
No
Total AMP service for electrical
*
Please select all recreational/farm or land service vehicles/equipment owned:
*
Motorcycle
Boat
ATV/UTV
Snowmobile
Segway
Golf cart
Scooter
Dirt bike
Jet ski
Tractor
Backhoe
Excavator
Dump truck
Skid-steer
Fork lift
Cultivator
Plow
Baler
Combine
Seed drill
Wagon
Front end loader
Cultipacker
Harrows
Irrigation system
Transplanter
Manure spreader
OTHER
NONE
Please indicate equipment description, value, and whether or not the unit is currently insured.
*
Please indicate any other property or land owned by you.
*
Have you had any bankruptcies in past 5 years?
*
Yes
No
Please explain:
*
Have you had any foreclosures in the past five years?
*
Yes
No
Please explain:
*
Have you had ANY claims at ANY property owned by you in the past five years?
*
Yes
No
Please explain (provide date, claim detail, amount paid, and if claim is open or closed:
*
Are you insured now?
*
Yes
No
Who was your last insurance carrier and expiration date of the policy?
*
Who is your current carrier and expiration date?
*
Do you have any special or unique personal property/or a large volume of one item you are concerned with covering? (jewelry, guns, antiques, electronics, musical instruments, tools, etc.) Please indicate a value and description.
*
Do you want us to quote any of the following?
*
Backup of sewer/drain
Equipment breakdown
Identity theft
Buried utility/service line coverage
Earthquake coverage
Flood coverage
Home based business
Umbrella coverage
NONE
Other
Select amount of coverage desired for Umbrella:
$1,000,000
$2,000,000
$3,000,000
$5,000,000
$10,000,000
Do you want Uninsured & Underinsured coverage added to your umbrella?
Yes
No
Have you had any prior Umbrella claims in the past 5 years? Please explain:
Is there anything else we should know about your property?
*
Best time/date to contact:
*
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