McKenzie Price Insurance_01-0751-00

Home Insurance Quote

Please complete the form accurately for better assistance
Name*

First NameLast Name
E-mail*
Date of Birth*

MonthDayYear
Phone Number

Area CodePhone Number
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Address of Home to Insure*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Policy Qualification Questions
Is this home a new Purchase? *

YesNo
If yes... Is the home a "foreclosure" or "short-sale"?

YesNo
If you already own the home... is the home currently insured?

YesNo
Additional Questions:
Is this house your primary residence?*

YesNo
If no... Is the home Seasonal, Vacant or Rental Property?
What year was the home built? - (feel free to estimate)*
Is the construction of the home BLOCK or FRAME?*
What year was the roof last replaced? - (feel free to estimate)
Is any part of the roof flat?*

YesNo
Have you had any bankruptcies, foreclosures or repossessions in the past 5 years?*

YesNo
Have you had a claim on any property in the last 5 years?*

YesNo
Do you own any of the following dogs: Pit Bull, Rottweiler, Doberman, Akita, Chow, German Shepard, Staffordshire or Terrier?*

Yes (... & I luv my pup)No
Is there a fire hydrant within 1000 feet of your home?

YesNo
E-mail
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Home Insurance Quote