NEXUS HOME QUOTE
Name
*
First Name
Last Name
Your Date Of Birth
*
-
Month
-
Day
Year
Pick a date
Marital Status
*
Please Select
Married
Single
Divorce
Living w/ significant other
Property Address to be insured
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Best Phone Number to reach you
*
Please enter a valid phone number.
Your Date Of Birth
*
-
Month
-
Day
Year
Pick a date
E-Mail Address
*
example@example.com
Name of Spouse or Co-Owner
First Name
Last Name
Spouse or Co-Owner D.O.B.
-
Month
-
Day
Year
Date
If you have moved in the past 3 years, what was your previous address?
Current Carrier Information
Who is your CURRENT home owner insurance company?
Enter Insurance Carrier Name
When does your CURRENT home owner policy renew?
-
Month
-
Day
Year
Next Renewal Date
Approximate Annual Premium
Wind Mitigation Inspection?
*
Yes
No
Four Points Inspection?
*
Yes
No
Elevation Certificate?
*
Yes
No
Tell Us About Your Home
Type of Home
*
Please Select
Single Family Residence
Townhouse
Condo
Manufactured House
Year Built
*
-
Month
-
Day
Year
Date
Square Footage
*
Year Home Purchased
*
-
Month
-
Day
Year
Date
1 or 2 Story Home
*
Please Select
1 Story
2 Story
Tri-Level
Basement
*
Please Select
Yes
No
Garage
*
Please Select
1 Car Garage
2 Car Garage
2 1/2Car Garage
3 Car Garage
3 1/2 Car Garage
4 Car Garage
1 Car Carport
2 Car Carport
How many FULL Bathrooms
*
Please Select
1
2
3
4
5
How many HALF Bathrooms
*
Please Select
0
1
2
3
4
5
Roof Type
Please Select
Concrete Tile or Clay Tile
Asphalt Shingles
Flat
Foam
Metal
Gravel
Tar
Other
Home Structure Type
*
Please Select
Frame
Block
Other
Swimming Pool
Yes
No
Diving Board
Yes
No
No Pool
Deductible
Please Select
$250
$500
$1000
$2000
Compare $500 vs$ 1000
Liability Protection Limit
Please Select
$500000
$300000
$100000
Medical Coverage
Please Select
$10000
$5000
$2000
$1000
Do you own a Dog?
Yes
No
Type of Dog
leave blank, if none
Any Dog BITE CLAIMS the past 5 years?
Yes
No
Not applicable
Any Scheduled Personal Property?
None
Guns
Collectibles
Jewelry
Other
Describe any Scheduled Personal Property and Coverage Amounts
leave blank, if none
Any Home Owner Claims?
Any Home Claims the past 3 Years?
Yes
No
Describe any home owner claims
May we help you in any other way?
Give me an AUTO quote
Yes
No
Quote my Boat, ATV, RV, Motorcycle, or Trailer
Yes
No
Life Insurance quote
Yes
No
Please provide any additional comments or questions here:
Referral Person (If Any)
AGENT NAME (If Known)
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