Blue Star Insurance Agency
Homeowner's Insurance Quote
Name
First Name
Last Name
Marital Status
Please Select
Single
Married
Widowed
Phone Number
Please enter a valid phone number.
Applicant Date of Birth
-
Month
-
Day
Year
Date
Social Security Number
XXX-XX-XXXX
Spouse Name
First Name
Last Name
Spouse Date of Birth
-
Month
-
Day
Year
Date
Spouse Social Security Number
XXX-XX-XXXX
Physical Address of Home
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is your mailing address different than your physical address?
Yes
No
Mailing Address
Mailing Address
Mailing Address Line 2
City
State / Province
Postal / Zip Code
Did you just purchase this home?
Yes
No
Date of closing?
-
Month
-
Day
Year
Date
Purchase price?
Value if different then purchase price?
What date did you purchase your home?
-
Month
-
Day
Year
Date
What is the name of the insurance company you had prior for coverage?
What date does your current homeowner's insurance expire?
-
Month
-
Day
Year
Date
What is the current yearly premium of your homeowner's insurance?
What is the current coverage amount of your homeowner's insurance?
What year was your home built?
What is the square footage of your home?
How many bathrooms are in your home?
What is the make of your home?
Please Select
Frame
Stucco
Adobe
Brick
Other
What is the make of your home if you chose "Other"?
What type of flooring does your home have? The percentage must add up to 100%.
List Type of Flooring
% of House
Type of Floor 1:
Type of Floor 2:
Type of Floor 3:
Type of Floor 4:
How many stories is your home?
One Story
Two Story
What type of roof does your home have?
Shingles
Metal
Tar and Gravel
Other
Do you have a mortgage on the home?
Yes, only 1 mortgage.
Yes, more than 1 mortgage.
No
Will we bill to escrow?
Yes
No
Describe roof if you chose "Other".
Primary heating source?
Gas
Electric
Other
Describe primary heating source if you chose "Other".
Vehicle storage:
None
1 Vehicle
2 Vehicle
3 Vehicle
Attached Garage
Attached Carport
Detached Garage
Detached Carport
Choose all that apply:
Fireplace
Wood Stove
Trampoline
Pool
Rails on All Steps
House Insurance Claim within the Last 5 Years
Require Flood Insurance
Flood insurance coverage amount needed:
Does your mortgage require a minimum deductible for flood insurance?
Yes
No
Flood insurance minimum deductible needed:
Do you have an elevation certificate?
Yes
No
What was the amount of your claim?
Please give a description of your claim.
Do you have pets?
Yes
No
How many pets do you have?
Please give us more information about your pets including breed, size, bite history if exists and # of each breed.
Example: 2 Chihuahua, Small, No Bite History
Please verify that you are human
*
Submit
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