IIP Insurance Agency_04-0217-00_Home Insurance Quote

Home Insurance Quote

IIP Insurance Agency
Please provide as little or as much information as you feel comfortable. We will contact you to fill in any important additional information.
Full Name 1:

First NameLast Name
Date of Birth:
Social Security #:
Driver’s License #:
Marital Status:
Occupation:
Phone Number:
Please enter a valid phone number.
Email:
example@example.com
Co-App Full Name 2:

First NameLast Name
Date of Birth:
Social Security #:
Driver’s License #:
Marital Status:
Occupation:
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physical Address (if different from above):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County:
Own or Rent Home:
Fire Dept. & Miles to Fire Dept.
Feet to Hydrant:
Current Insurance Carrier:
Requested Eff Date:
Dwelling Information
Year Built:
Purchase Date:
Market Value:
# of Families:
Square Feet:
Construction Type:
# of Stories/Style:
Type of Foundation:
Basement____%?
Finished____%?
Crawlspace____%?
Slab___%?
Garage(s):

AttachedDetachedBuilt InN/A
# of Cars or Square Feet:
# of Bathrooms - Full
# of Bathrooms - 3/4
# of Bathrooms - 1/2
# of Fireplaces - Wood
# of Fireplaces - Gas
# of Fireplaces - Electric
Wood/Corn Pellet Stove
Exterior:
Brick____%?
Brick Veneer____%?
Vinyl____%?
Wood____%?
Other Type____%?
Age & Type:
Roof:
Plumbing:
Electrical:
Heating:
Central or Window A/C:
Porch Type & Size:
Deck Type & Size:
# & Breed of Pets
Check if Applicable:

GazeboTrampolinePoolShedHot Tub
Other Exterior Features:
Coverages
Dwelling:$
Liability:$
Med Pay:$
Deductible:$
Optional Coverage (Water Back-Up, Earthquake, Mine Subsidence, Jewelry/Guns, etc.):
Prior Claims

List Prior Claims:

	Date:	Type:	Amount Paid:	Damages Repaired?
Claim:
Claim:
Claim:
Claim:

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