Home Insurance - Quote Form

Home Insurance - Quote Form

Joey Alfred
Insured's Name*

First NameLast Name
Gender*
Insured's Email Address*
example@example.com
Insured's Phone Number*
Please enter a valid phone number.
Insured's Date of Birth*

MonthDayYear
Date
Insured's Social Security Number
Location Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Would you like to enter a different mailing address from the previous one entered?*

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Have you lived at this address more than 60 days (2 months)?*

Previous Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Insured's Employer's Name*
Length of Employment*
Ex: 5 years
Insured's Occupation*

Insured's Marital Status*

Spouse Info
Spouse's Name*

First NameLast Name
Spouse's Gender*
Spouse's Date of Birth*

MonthDayYear
Date
Spouse's Social Security Number
Insured's Employer's Name*
Length of Employment*
Ex: 5 years
Insured's Occupation*

House Purchase/Closing Info
Date of Purchase/Closing*

MonthDayYear
Date
Purchase Price*
Ex: $150,000
Amt of Coverage Desired on Property*
Ex: $200,000
Year Built*
Ex: 2021
If your house was built before 1965... Is your Electric Circuit Breaker Present?
Is your current Liability Limit on your current home policy above $300,000?
Deductible Details
Ex: 1% of Dwelling Coverage - Most carriers are requiring a 1-3% wind/hail deductible.. but if you want something more (ex: $5,000, etc.) please list it here.
Amt of coverage desired for your Personal Property (Content/Belongings)?
Ex: $50,000 - Your furniture, clothes, sports equipment and other personal items are covered if they are stolen or destroyed by fire, hurricane or other insured disaster. Most companies provide coverage for 50% to 70% of the amount of insurance you have on the structure of your home. So if you have $100,000 worth of insurance on the structure of your home, you would have between $50,000 to $70,000 worth of coverage for your belongings. The best way to determine if this is enough coverage is to conduct a home inventory.

Home Structure Details
Construction Type*
Exterior Type*
Foundation Type*
Total Square Feet*
Ex: 3,000
Type of Roof*
Age or Year of Roof*
Ex: 5 years or 2018

#of Stories*
#of Bedrooms*
# of Full Baths*
# of 1/2 Baths*
Garage/Carport*
# of Cars*
# of Cars that can be parked in the Garage
Do you have a covered Patio or Porch?*
Size of Patio or Porch (Sq Ft)*
Ex: 250 Sq Ft
Primary AC Source (Air Conditioning)*
Primary Heat Source*
List any other Primary or Secondary Heating Sources (Oil, Solid Fuel, Other) Please explain details below.
Ex: Oil, Solid Fuel, Other

Does property have a Fireplace?*

Fireplace Details
Fireplace type?*
# of Fireplaces in the home?*
# of Chimneys?*
List any other details you would like to share regarding the Fireplace?

Alarm System?*
# of Fire Extinguishers?*
Responding Fire Dept?*
Ex: PVFD
Distance (in miles) to Fire Dept?*
Ex: 5 miles
Distance (in feet) to Fire Hydrant?*
Ex: 100 Feet
# of Smoke Detectors?*

Does this property have a Swimming Pool?*

Swimming Pool Details
Swimming Pool Type?*
Swimming Pool Accessories?*
If Above Ground Swimming Pool - Ladder Lock?*
Is Swimming Pool Fenced?*
Does Swimming Pool have a lock on the Fence?*
List any other details you would like to share regarding the Swimming Pool

Do you have any Pets?*

Pet Details
List Breed and Weight of all Pet(s)*

Does this property have a Trampoline?*

Trampoline Details
Is Trampoline fenced?*

Any Acreage on Property?*

Acreage Details
Size/How many acres on Property?*
Ex: 3 Acres

Do you have a Business on the property/premise?*

Business on Property Details
Explain the Type of Business on the property/premise?*

Do you have any other structures on the property?*

Other Structures Details
List any other structures on the property - Size, Construction Type, and What it is used for?*
Value of Other Structure
Ex: $50,000 - The default amt on a policy is usually 10% of the dwelling amt (Ex: if house is insured for $200,000... other structure coverage would be $20,000) - IF YOU NEED MORE COVERAGE ON THIS STRUCTURE, PLEASE ADD TOTAL AMOUNT.

Have you had any updates to the your home?*
Ex: Wiring, Plumbing, Heat/Air, Roof - Updates are required for Homes that are over 40 years old.

Update to the Home Details
Wiring (year updated)*
Enter the year Wiring was update - Ex: 2019 - If no updates have been made... Enter the year your house was built.
Plumbing (year updated)*
Enter the year Plumbing was update - Ex: 2019 - If no updates have been made... Enter the year your house was built.
Heat/Air (year updated)*
Enter the year Heat/Air was update - Ex: 2019 - If no updates have been made... Enter the year your house was built.
Roof (year updated)*
Enter the year Roof was update - Ex: 2019 - If no updates have been made... Enter the year your house was built.
List update Details you have had to your home regarding Wiring, Plumbing, Heat/Air, Roof and date it was replaced/updated*

Have you ever been convicted of Arson?*

Arson Details
List Details on Conviction of Arson*

Have you ever filed Bankruptcy or had any Judgments in the last 5 years?*

Bankruptcy Details
List Bankruptcy date and details on any Judgments*

Have you had any Claims in the last 5 years?*

Claims Details
List all Claims within the last 5 years
List the Date, Type of Loss & Amount Paid Out
Date of Loss of Claim?
Ex: 5/20/2922
Amount paid out for Claim?
Ex: $4,500
Has this Claim been closed?

Current Coverage Details
Current Insurance Carrier Name
Current Premium Amount
Exp Date of Current Insurance Policy
# of Months/Years with Current Carrier
Current Coverage Amounts
If you know and/or have this info... Please list your Deductible and coverage amounts for the following... Dwelling, Deductible, Personal Liability, Medical Payments, Personal Property, etc.
Upload Current Policy (If you have it)

If possible, please upload the declarations page of your current insurance policy for this vehicle.
Cancelof

Do you currently have (or plan to have) a Mortgagee on this property?*

Mortgagee #1 Details
Loan #
List loan number if you know it
Mortgagee Name Address
Ex: ABC Bank - Address, St, Zip (leave blank if you don't have a mortgagee)

Do you currently have (or plan to have) a 2nd Mortgagee on this property?*

Mortgagee #2 Details
Loan #
List loan number if you know it
Mortgagee Name Address
Ex: ABC Bank - Address, St, Zip (leave blank if you don't have a mortgagee)

Additional Comments or Details before submitting
Any additional Comments, etc
Please list or explain any other details that you think we need to know regarding your home.
Should be Empty:

Home Insurance - Quote Form

Spouse Info

House Purchase/Closing Info

Home Structure Details

Fireplace Details

Swimming Pool Details

Pet Details

Trampoline Details

Acreage Details

Business on Property Details

Other Structures Details

Update to the Home Details

Arson Details

Bankruptcy Details

Claims Details

Current Coverage Details

Mortgagee #1 Details

Mortgagee #2 Details

Additional Comments or Details before submitting