Home Quote Form

How did you hear about us?*

Explain:

Who is filling out this form?*

Are You A Current Client?*

YesNo

Are you currently working with anyone in our agency?*

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Do we have permission to communicate via text with you at this number?*

YesNo

Email*

example@example.com

Occupation (If Retired what occupation did you retire from?)

Date of Birth*

Date

Marital Status

Relationship to Primary Insured

Secondary Insured

First NameLast Name

Secondary Insured's Date of Birth

Date

Secondary Insured Occupation (If Retired what occupation did you retire from?)

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mailing address if different from above:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Desired Coverage Start Date*

Date

Is this home a new purchase?*

If yes, what is your expected close date?

Date

Previous address if new purchase or less than 4 years occupancy:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Type*

If your home type is Other, please explain:

What is your home usage?*

If your home use is less than primary, How many months of the year is the home occupied:

What year was your home built?

What is the square footage of your home?

How many stories is your home?

Water Heater Year*

What year is your roof?*

Roof Material

Plumbing Type

Exterior Wall Finish

What type of flooring do you have in your house? If multiple, please give an estimate on % of each kind.

Foundation Type

Other:

Do you have the following:

	Yes	No
Monitored Central Burglar Alarm
Monitored Central Fire Alarm
A Fire Hydrant outside within 1000 Feet of your home
Do you live in a gated community?
Do you have a fire place?
Have you filed for bankruptcy, Foreclosure, Repossession or Short Sale in the past 5 years?
Have you had your home insurance canceled, non-renewed or denied coverage?
Is the property located on more then 5 acres?
Is the home built OVER water?
Has the property had any sink hole activity?
Do you have dogs that breed is considered high risk? (if yes, what breed)
Swimming Pool?
Do you need screen enclosure coverage?

Who was your previous carrier?

When does your current/previous policy expire?

Date

Have you had any claims on this property or any other property within the last 5 years? If yes, please explain and give approximate dates. *

Please upload current declarations page if available

Any additional notes you would like us to know?

Insurance Score Disclosure:

In order to provide you with an accurate insurance quote, it is necessary for our affiliated carriers to review your credit report and utilize a credit-based insurance score. This score is derived from the information contained within your credit report and aids in determining whether to insure you and what premium rate to charge. Many carriers may utilize third-party entities in connection with the development of your insurance score. This information may also be utilized to provide you with quotes for other insurance products offered by the Amanda Campbell Agency.The Department of Financial Services offers free financial literacy programs designed to assist individuals with insurance-related inquiries, including understanding how credit functions and how credit scores are calculated. For further information, we encourage you to visit www.MyFloridaCFO.com.By requesting an insurance quote from us, you acknowledge and agree to the aforementioned credit review and utilization of credit-based insurance scores for quoting purposes.If you have any questions or concerns regarding this disclosure, please do not hesitate to contact us.