Home Insurance Quote Request
Allenbaugh Insurance Agency
Your Name:
*
First Name
Last Name
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email:
*
example@example.com
Property Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
At address 2 years or more?
Yes
No
If 'No' what was your prior address:
Mailing Address (if different from above):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is this a new purchase?
Yes
No
Is this your primary residence?
Yes
No
Is there a mortgage on the home?
Yes
No
If yes, with who and is it escrowed?
Marital Status:
Single
Married
If Married, Spouse's Name:
First Name
Last Name
Your Date of Birth:
If Married, Spouse's Date of Birth:
Currently Insured?
Yes
No
If 'Yes' how long insured?
Present Company:
Present Coverages (or upload docs below):
Any Claims?
Yes
No
Any Bankruptcy or Foreclosure?
Yes
No
If 'Yes' what year was Bankruptcy or Foreclosure?
Year Built:
Year of Known Updates:
Construction Type:
Square Footage:
Roof Type:
Roof Shape:
Foundation Type:
Please Select
Crawlspace
Basement
Slab
If basement, is it finished and if so what percent?
Any buildings or other detached structures on the property? If yes, please indicate approximate size and value of each.
Do you have an alarm?
Yes
No
Heating/Cooling Type:
How Much Property:
Please indicate all applicable information below:
Within the City Limits?
Yes
No
Type of Road:
Paved
Dirt
Nearest Fire Department:
Distance:
Fire Hydrant Distance:
Are there any fireplaces? If yes, how many and are they wood or gas burning?
Do you have a pool?
Yes
No
Is the pool fenced in?
Yes
No
Does the pool have a slide?
Yes
No
Does the pool have a diving board?
Yes
No
Do you have a trampoline?
Yes
No
Do you have dogs?
Yes
No
If 'Yes' how many dogs:
What breed(s):
Do you have farm animals?
Yes
No
If 'Yes' what type of farm animals:
Upload Homeowners Declaration Sheet (not required):
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