Home Insurance Quote Form
Crawford Insurance Agency
Today's Date:
-
Month
-
Day
Year
Date
Your Name:
*
First Name
Last Name
Phone:
*
-
Area Code
Phone Number
Email:
*
example@example.com
Current Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Township:
How Long at Current Address?
Previous Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Fire Department Distance (in miles):
Hydrant (in feet):
Flood Zone?
Yes
No
Previous Insurance Carrier:
Expiration Date:
Coverages:
Marital Status:
Single
Married
If Married, Spouse Name:
First Name
Last Name
Spouse Date of Birth:
Your Date of Birth:
Occupation:
Group Discount (i.e. credit union or AARP, which credit union)?
Any Claims in the Last 5 Years? (after clicking "Save Claim" you may add another claim)
HOUSE INFORMATION
Year Home Built:
Type of Construction:
Brick
Masonry
Wood Frame
Roofing Material:
Siding:
Vinyl
Aluminum
Wood
Brick
Stone
How many stories?
1 ½ STORY
2 STORY
BI-LEVEL
TRI-LEVEL
Basement?
Yes
No
If yes, percent finished?
Walk-Out?
Crawl Space:
Slab:
Material:
APPROX SQ FT - 1st Floor
TOTAL SQ FT:
Value:
Wood Burning Stove?
Yes
No
If yes, where located( i.e.: dwelling, outbuilding)?
Wiring/Circuit Breakers - breaker box or knob and tube (glass fuses)?
Fireplace(s):
Gas
Wood
N/A
Smoke Alarms?
Yes
No
Fire Extinguishers?
Yes
No
Any Smokers in the household?
Yes
No
Automatic Back-up Generator?
Yes
No
Alarm System?
Yes
No
Skylights?
Yes
No
Any Garages?
Yes
No
If yes, is Garage?
Attached
Detached
Number of Cars:
1
1.5
2
2.5
3
Porch?
Yes
No
If yes, is porch:
Open
Enclosed
If yes, porch size:
Deck/Balcony?
Yes
No
If yes, deck/balcony size:
Any Outbuildings?
Number of Full Bathrooms:
Number of Half Bathrooms:
Type of Heating:
Central Air?
Same Ducts as Furnace?
Home Purchase Date:
-
Month
-
Day
Year
Date
Amount:
Mortgage?
Is Insurance paid from Escrow?
If yes, mortgagee:
Is the home occupied?
If not, when?
Pool?
Yes
No
If yes, is the pool:
Above Ground
In-Ground
Fenced?
Yes
No
Locked Gate?
Yes
No
Trampoline?
Yes
No
Do you have any pets?
Yes
No
If yes, what kind?
If dogs, what breed?
UPDATE YEAR
Roof, year updated:
Wiring, year updated:
Plumbing, year updated:
Heating, year updated:
IF MOBILE HOME:
*
How did you hear about us?
*
Please verify that you are human
*
Submit
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