Homeowner Insurance Quote Form
Norgaard Agency, Inc.
How did you hear of Norgaard Agency?
*
Your Name:
*
First Name
Middle Initial
Last Name
Partner's Name (if applicable):
First Name
Middle Initial
Last Name
Property Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
At address 2 years or more?
Yes
No
Prior Address:
Mailing Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
New Purchase?
Yes
No
Primary Residence?
Yes
No
Marital Status:
Single
Married
Home Phone:
-
Area Code
Phone Number
Cell Phone:
-
Area Code
Phone Number
Work Phone:
-
Area Code
Phone Number
Your Email:
*
Your DOB:
Partner's DOB (if applicable):
Policy Desired:
Homeowners
Condo
Landlord/Dwelling Fire
Renters
Currently Insured?
Yes
No
Name of current insurance carrier, if applicable:
How long have you been with current carrier?
Any home claims in the last five years?
Yes
No
How do you typically pay?
Monthly
Pay in Full
Bankruptcy or Foreclosure:
Yes
No
Year of Bankruptcy or Foreclosure:
Is there a loan on the home? If so, please list the mortgagee and their mailing address.
UPDATES:
Year Built:
Construction Type (Frame, Modular, Mobile, Manufactured):
Square Footage (above ground):
Roof - Year of Last Update:
Heat - Year of Last Update:
Plumbing - Year of Last Update
Electrical - Year of Last Update
Roof Type (Shingle, Metal, Rubber, etc.)
Do you have outbuildings that require scheduling? If so, how much of an additional value do you want?
Heating Source & Year of Last Update:
Any wood/pellet heat (solid fuel), if so please describe:
Foundation:
Slab
Crawlspace
Finished Basement
Partially Finished Basement
Unfinished Basement
Central Station Alarm?
Yes
No
Lot Size/Acres:
Within the City Limits?
Yes
No
Distance to Nearest Fire Department:
Fire Hydrant Distance:
Pool?
Yes
No
Fenced?
Yes
No
Slide?
Yes
No
Diving Board?
Yes
No
Trampoline?
Yes
No
Dogs?
Yes
No
# of Dogs:
Breed:
Farm Animals?
Yes
No
Type:
Upload Homeowners Declaration Sheet
Browse Files
Cancel
of
If not uploading declarations page, please provide the following (dwelling coverage (Cov A), other structures (Cov B), liability coverage, deductible, and any other notable endorsements/riders):
When do you need this quote/when does your current coverage expire?
-
Month
-
Day
Year
Date
Form completed by:
*
Verification Code - enter the message as it's shown:
*
Click here to view our
Privacy Policy
.
Submit
Should be Empty: