Home Insurance Request for Quote
Person & Contact Details
How did you hear about us?
Please Select
A customer referred me
Google
Website
Saw Our Sign
George Restaurant
Mortgage Lender Referred Me
My Relator Referred Me
Name
*
First Name
Last Name
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? By selecting Yes, you agree to receive text messages from Spitzer Insurance Agency . Message frequency may vary. Message and data rates may apply. Text HELP for assistance. To opt-out at any time, reply STOP.
*
Yes
No
Date of Birth (Required to Quote)
*
-
Month
-
Day
Year
Martial Status
Please Select
Single
Married
Divorced
Property Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (if different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Building Details
We require some information about your building to do an accurate quote for building insurance.
Is the home a new purchase?
Yes
No
What is your home usage type?
Please Select
Owner Occupied
Rented to Other
Vacant
Please select your type of home
*
House
Townhouse
Condo
Duplex
Triplex
How many stories is your home?
Please Select
1 Story
1.5 Story
2 Story
Tri level
Bi Level
Type of Foundation
Please Select
Slab
Crawl Space
Basement
Walkout Basement
Exterior of Construction of Property
Please Select
Frame
Masonry
Mixed Frame-Masonry
Aluminum
Hardyboard
Other
Roof Material
Please Select
Shingles
Metal
Tile
Other
When was your roof last replaced?
Are you wanting replacement cost coverage?
Please Select
Yes
No
Both
How much coverage are you wanting to insure the property?
Are there any detached structures you are wanting to insure?
Please Select
Yes
No
Example: Detached Garage, Shed, Fence
If yes, please provide details on what you would like insured and how much coverage.
Example: Detached Garage $10,000
Do you have a swimming pool?
Yes
No
Do you have a tramploine?
Yes
No
Is your yard fenced?
Yes
No
Any additional notes you would like us to know?
Example: Extra Riders - Water Back up, Service Lines
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Please upload current declaration page if available.
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