Christopher P. Shipley Insurance Agency
Homeowners Quote 863-738-8123
Personal Information
Name
*
Mr.
Mrs.
Prefix
First Name
Middle Name
Last Name
Suffix
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Date Of Birth
*
Spouse's Name/2nd named insured
N\A
Mr.
Mrs.
Prefix
First Name
Middle Name
Last Name
Suffix
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth
Prefered Contact Person
Named Insured
2nd Named Insured
Either One of Us
Prefered Peron and method of contact (you can choose more than one option)
Mornings 10a-12P
Afternoons 12P-6P
Evenings 6P-10P
Call Anytime
Text Anytime
Email Anytime
Address of property to be insured
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Previous Address (if less than 10 years)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address if Different from above
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
When Do You Need The Insurance Effective?
-
Month
-
Day
Year
Usually this is the day you close on a new purchase or the day after your current policy expires. We can start a new policy at anytime if you are cancelling your current policy
What Type Of Home Insurance Do You Need?
*
Rental Dwelling Coverage - I do not live in the home but I own the home
Homeowners Coverage - I live in the home and I own the home (either: permanent or seasonal)
Is There a Mortgage On The Home?
*
Yes (Will need mortgagee information to issue policy)
No
Is Your Home Currently Insured?
*
Yes
No
Current Insurance Carrier
*
Last Year Roof Was Replaced?
*
Year of Heating & Air Conditioner Replacement?
*
If original unit type Original
Do you have a Centrally Monitored BurglarFire Alarm?
*
Please Select
Yes - Both are actively monitored
Yes- Burglar only
No
Installed but not monitored
If centrally monitored we will need certification from the monitoring company to apply any discounts
When Did You PurchaseLease the home?
*
Approximate Month and Year
SqFt Of Home
*
Any Claims In The Last 5 years? Please list Year of Claim, Nature Of Claim, Amount of Claim, if the claim is settled and all repairs made.
Year, Nature, Amount, Settled, Repairs Completed
Would You Like a Flood Insurance Quote?
*
Yes
No
Nope I'm building an Ark
How Did You Hear About Us?
*
Thank You For Requesting Your Quote Online
I or an individual acting on my behalf, request a quote based on the information provided in this form. I or an individual acting on my behalf, understand that no insurance is bound by completing this form to request a quote. I, or an individual acting on my behalf, further understand that Christohpher P Shipley Insurance Agent, associates and other affiliated parties will search multiple insurance companies, brokerages and agencies in an attempt to find me the lowest possible price, and will continue to retain my information for this purpose and will contact me by phone call, text (if approved above) and/or email with said quotes or to gather additional information for the quotes if needed. I or an individual acting on my behalf, understand that these quotes are only provided for individuals and/or companies that are domiciled in the State of Florida.
*
I or an individual acting on my behalf, approve and agree with the above terms
Are You Human, Alien or Artificial Intelligence?
*
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