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Home Quote Form
How did you hear about us?
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Google
Facebook
Other Social Media
A Customer Referred Me
Print Media/Ad
Saw Your Sign
Met An Agent At An Event
My Mortgage Lender Referred Me
My Realtor Referred Me
BNI
B. Brown
Are you already working with a team member at Schultze Agency? If so, select one:
Please Select
Jeff Schultze
Jaime Schultze
Nicolle Borton-Cobuccio
Other/not working with anyone
Name
*
First Name
Last Name
Date of Birth
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Month
/
Day
Year
Date
Marital Status
Please Select
Married
Single
Divorced
Occupation (If Retired what occupation did you retire from?)
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Do we have permission to communicate via text with you at this number?
*
Yes
No
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is Mailing Address the same as the physical address?
Yes
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Secondary Insured
First Name
Last Name
Secondary Insured's Date of Birth
/
Month
/
Day
Year
Date
Desired Coverage Start Date
*
/
Month
/
Day
Year
Date
Is this home a new purchase?
*
Please Select
Yes
No
What is your home usage type?
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Please Select
Owner Occupied
Rented to Others
Owner Occupied part time and rented to others part time
Vacant
What year was your home built?
What is the square footage of your home?
How many stories is your home?
What year is your roof?
Roof Material
Please Select
Shingles
Metal
Tile
Other
Plumbing Type
Please Select
Copper
Galvanized
PEX
Polybutylene
PVC
Wall Type
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Masonry
Frame
Mixed Masonry-Frame
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 than 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 solar panels
Do you have a pool?
Do you have a trampoline?
Please upload current declarations page if available
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Any additional notes you would like us to know?
Would you like an AUTO quote as well?
*
YES
Not at this time
How many drivers in the household?
Please provide the name(s) and DOB(s) for any drivers not already listed on the home quote above:
Please list the year, make & model of all vehicles to be included on the policy:
DL number(s) & state for each driver
Comprehensive Deductible
$1,000
$500
Other Amount
No Coverage
Collision Deductible
$1,000
$500
Other Amount
No Coverage
Please select all additional coverages that are important to you:
Rental
Towing/Roadside
Glass Covergae
Rideshare
Please provide any additional information that you would like to share related to your auto quote.
Are you interested in a free, no obligation Life Insurance quote?
*
Yes
Not at this time
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