Home Insurance Quote

Home Insurance Quote

Please fill the form as completely as possible for better assistance. The email box that this form is submitted to is monitored continuously and someone will be in touch with you very shortly once the form is submitted. All Data is encrypted. Landsman Insurance Services, LLC. NPN: 21500715 - 1-833-208-0034 NOTICE: ANY PERSON WHO, KNOWINGLY OR WITH INTENT TO DEFRAUD OR TO FACILITATE A FRAUD AGAINST ANY INSURANCE COMPANY OR OTHER PERSON, SUBMITS AN APPLICATION OR FILES A CLAIM FOR INSURANCE CONTAINING FALSE, DECEPTIVE OR MISLEADING INFORMATION MAY BE GUILTY OF INSURANCE FRAUD.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Name of person submitting the form if not the Policyholder (Mortgage Agent or Real Estate Agent)

First NameLast Name
Email address of person submitting the form if not the Policyholder (Mortgage Agent or Real Estate Agent)
example@example.com
Address to be covered*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mailing Address (Only fill out if different from the above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How Long at Current Mailing Address?*
Is this a new purchase or existing home you own?

NewExisting
Have you had a policy cancelled or non-renewed by your insurance carrier in the past 5 years?*

YesNo
Phone Number*
E-mail*
example@example.com
Are you searching for coverage for?

Condo / Co-opSingle Family HomeMultiple Family HomeTownhouseMobile Home
Please upload a copy of your current policy (if applicable) This is so we can quickly evaluate your current coverage and offer you like and similar coverage along with suggestions for enhancements. If you are a mortgage broker or real estate agent, please upload a copy of the listing for the property.

Cancelof
Year Built
Construction type (wood frame, brick etc.)
Square Footage
# of Stories
Number of Bedrooms
Number of Baths
Does any of the home's plumbing contain cast iron or galvanized steel?*

YesNo
Pool?

YesNo
If Yes

In GroundAbove Ground
Pool Sq. Ft.
Is the pool fenced separately from the yard?

YesNo
Is the yard Fenced?

YesNoNot Applicable
Trampoline?

YesNo
Finished Basement?

YesNo
If yes to Finished Basement what % is finished?
Knob or Tube Wiring?*

YesNoUnknown
Any hazardous conditions nearby? (Vacant properties, landfill, factory, etc.)*

YesNoUnknown
Alarm?

Yes, burglarYes, fireYes, bothNo
Centrally Monitored?

Yes,No
Does anyone in the house smoke any product that uses an open flame to light (i.e. cigarettes, Cigars, Pipe, Medical or Recreational Marijuana)? Do not include Vapes

Yes,No
Roof Type
Please Describe
Age of Roof Age of roof in years (important). If not available please enter "Unknown". *
Garage (# of Cars)
Enter 0 if no Garage...
Floor types
Please list all flooring types (Tile/Carpet/Laminate/etc.)
Percentage of each flooring type?
What% of each flooring type? (Example 70% Tile 30% Carpet)
Last Month/Year Update to Electrical?*
Please list and provide approx month/year of update for each. If none please state none.
Last Month/Year Update to Plumbing?*
Please list and provide approx month/year of update for each. If none please state none.
Last Month/Year Update to HVAC?*
Please list and provide approx month/year of update for each. If none please state none.
How old is the water heater?*
If unknown please type unknown.
Claims in last 5 years?
Please include Month / Year / Amount / Description for each
Year Built
Home Sq. Ft.
Patio Sq. Ft.
Porch Sq. Ft.
Is this for a new home purchase or one you currently own?

NewCurrent
Do you currently have insurance on this property?

YesNo
Has the home been vacant for the last thirty days?*

YesNo
Do you rent out any part of the home more than 7 days a year?*

YesNo
Do you currently have a mortgage on the house?*

YesNo
If yest to above, do you have a private mortgage? (That’s a loan from a family member, friend, or non-commercial lender)*

YesNoN/A
Please include any other notes or relevant information here (Pets? #, breed, size, any history of biting or aggressive behavior?)
Should be Empty: