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Homeowners Insurance Info Request Form

For over 40 years, Langlois Insurance Agency has helped families protect what matters most. Complete the form below and one of our licensed agents will review your information and shop for the best coverage options available.
📞 Questions? Call us at #815-485-2106 🕘 Monday–Friday | 8:00 AM– 4:30 PM
Owner/First Named Insured

First NameLast Name
Owner/First Named Insured Date of Birth

MonthDayYear
Date
Co-Owner/Second Named Insured (if applicable)

First NameLast Name
Co-Owner/Second Named Insured Date of Birth

MonthDayYear
Date
Main Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Main Email
example@example.com
Preferred method of contact (phone, email, text, other)
Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
Marital Status
How did you hear about Langlois Insurance Agency?
If you were referred by a current customer, please let us know their name so we know who to thank!
Do you currently have Home Insurance?
Is your current Home Insurance policy active?
Please upload a copy of your current Home Insurance policy (PDF, JPG, PNG)

Cancelof
Property to be Insured:

Street Address

Street Address Line 2

CityState

Zip Code
Is this your:
Desired Effective Date

MonthDayYear
Date
HOME DETAILS
Year the home was built
Square footage
Number of stories
Type of Construction
Roof Type
Year the Roof was Replaced
Foundation Type
Garage Type
Number of Bedrooms
Number of Bathrooms
Estimated Personal Property Value
HOME SYSTEMS & UPDATES
Is the electrical system updated?
If yes, what was the year it was updated?
Is the plumbing system updated?
If yes, what was the year it was updated?
Is the heating system updated?
If yes, what was the year it was updated?
Do you have central air conditioning?
Any wood burning stove or fireplace?
Any solar panels?
If yes, are they owned or rented? And how many panels?
OCCUPANCY QUESTIONS
Do you own any pets?
If yes, how many and what type/breed?
Do you own a swimming pool?
If you do have a pool, is it fenced?
Do you own a trampoline?
Do you run a business out of your home?
Do you have any claims in the last 5 years?
If yes to a claim, what was the date of claim?
If yes to a claim, what was the type of claim?
Any bankruptcy or foreclosure in the last 5 years?
COVERAGE PREFERENCES
What type of coverage are you looking for?
MORTGAGE INFORMATION
Is there a mortgage on the property?
If yes, what is the Mortgage Company Name?
Escrowed through the Mortgage Company?
ADDITIONAL INFORMATION
Is there anything additional that you would like us to know about this property? (ex. recent renovations, prior insurance concerns, desired coverage questions, closing timeline, etc...)
Are you interested in bundling other policies (please check all that apply):
I understand that submitting this form does not bind coverage. A licensed representative from Langlois Insurance Agency will contact me to review coverage options and finalize any policy."
Should be Empty:

Homeowners Insurance Info Request Form

HOME DETAILS

HOME SYSTEMS & UPDATES

OCCUPANCY QUESTIONS

COVERAGE PREFERENCES

MORTGAGE INFORMATION

ADDITIONAL INFORMATION