Home Insurance Quote Request
Rux Carter Insurance Agency, Inc.
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
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?
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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