Home Quote Form

How did you hear about us?*

Name*

First NameLast Name

Date of Birth*

Date

Marital Status

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

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

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

YesNo

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Secondary Insured

First NameLast Name

Secondary Insured's Date of Birth

Date

Desired Coverage Start Date*

Date

Is this home a new purchase?*

What is your home usage type?*

What year was your home built?

What is the square footage of your home?

How many stories is your home?

What year was your roof last replaced?*

Roof Material

Plumbing Type

Wall Type

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

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?
Are there any dogs with bite history?
Do you have a trampoline on the premises?
Do you have solar panels on the premises?
Do you have a pool on the premises?
Is the dwelling isolated (not visible from the main road or neighbors)?

Please upload current declarations page if available

Any additional notes you would like us to know?

“In connection with this application for insurance, Farmers and Pettigrew Agency partners/affiliates may review your and your spouse’s credit report or obtain or use a credit-based insurance score based on the information contained in that credit report. We may use third parties in connection with the development of your insurance scores based on data from traditional credit bureaus and the National Consumer Telecom & Utilities Exchange database.” Also, do you consent for Farmers and Pettigrew Agency partners/affiliates: (1) to access any available driving scores from a third party based on vehicle telematics data, (2) to use any consumer report information their affiliates might currently have for you for this transaction, and (3) to share consumer report information from this transaction with their affiliates to quote other products?*

Yes, I Consent