Home Insurance Quote

Home Insurance Quote
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date of birth*
Is this also the Mailing Address?*

YesNo
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail
# of Bedrooms*
# of Baths*
Pool Area Screened?

YesNo
Is the yard Fenced?

YesNo
Roof Type*
Please Describe
Age of Roof*
Garage (# of Cars)*
Enter 0 if no Garage...
Floor types*
Please list all flooring types (Tile/Carpet/Laminate/etc.)
Percentage of each flooring type?
What% of each flooring type? (Example 70% Tile 30% Carpet)
Updates to Electrical, Plumbing, or A/C?*
Please list and provide approx month/year of update for each.
Claims in last 5 years?*
Describe what type and how much was paid
What type of homeowners insurance do you need?*
Purchase Date (approximate)*

MonthDayYear
Date
How much would it cost to replace your home/residence (minus land value)*
Number of stories
Number of acres
Distance to fire department (in miles).*
Distance to fire hydrant (feet)*
Is this your primary or secondary residence?*

PrimarySecondaryRentalVacationFarm
Is property located within city limits?*

YesNo
Occupancy type*
#Familes *
Construction type
Foundation type
Primary source of heat*
Do you have an alternate source of heat other than a fireplace (e.g. wood burning stove)*
Year electrical upgraded*
Do you have circuit breakers*
Year heating was upgraded
Year plumbing was upgraded
Do you operate a business on the property?
Please click all that appl*

Hot TubSwimming poolTrampolinePitt bullDobermanGerman ShepherdAny dog with prior bit historyNone of the above
Name of current homeowners insurance
Information Agent can get from County Website
Year Built
Home Sq. Ft.
Pool Sq. Ft.
Patio Sq. Ft.
Porch Sq. Ft.
1STOP INSURANCE AGENCY

1340 Commercial Blvd, Herculaneum, MO 63048

www.1Sinsurance.com

www.SR22.me
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