Home Insurance Quote Form

PAGE INSURANCE
Home Insurance Quote Request
SECTION 1 - About You

Required
Name*

First NameLast Name
DOB*

MonthDayYear
Date
Marital Status*
Occupation*
E-mail*
Phone Number*
Other Named Insured?*

YesNo
Spouse / Other Named Insured*

First NameLast Name
Spouse / Other DOB*

MonthDayYear
Date
Occupation*
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
SECTION 2 - Current Insurance & History

Required
Effective / Closing Date*

MonthDayYear
Date
Is this a new purchase?*

YesNo
Current Insurance Company:*
Current Insurance Premium:*
Have you had continuous coverage for the past 12 months?*

YesNo
Any cancellation / non-renewal in the past 3 years ?*

YesNo
Cancellation: If YES, please provide a short explanation.
Any claims in the past 5 years ?*

YesNo
If yes to claims, please provide more information here:
Please include: Date of loss, type of loss, approximate amount paid, and whether the claim is open or closed.
Has the home ever had water damage, foundation issues, or structural settlement?*

YesNo
SECTION 3 - Property Overview

Required
Location Address is the same as the mailing address
Location Address*

Street Address

Street Address Line 2

CityState

Zip Code
Year Built*
Square Footage
Number of Families*

1234
Usage Type*

PrimarySecondarySeasonalRental
Occupancy*

Owner OccupiedTenant OccupiedOwner Occupied with Some Rental
If tenant occupied or rental, how many weeks is it rented per year?
Do you rent to college students or anyone under the age of 21?

YesNo
If Tenant Occupied, do you have an annual lease?

YesNoN/A
Is there any of the following short term/property sharing rental exposure:

AirBnBVRBOHipCampNone
SECTION 4 - Construction & Systems

Required
Construction Type

FrameMasonryOther
Type of Basement
Year Roof Last Replaced*
Enter year (YYYY)
Year Electrical Last Updated*
Enter year (YYYY)
# Amps*

60100200

Circuit Protection*

Rows	Yes	No
Circuit Breakers
Any fuses?
Knob/Tube Wiring

Year Plumbing Updated*
Enter year (YYYY)
Year Heating Updated*
Enter year (YYYY)
Type of Heat*

OilGasElectricPropane
Location of Oil Tank:*
Do you have city water?*

YesNo
Within 1,000 ft of a fire hydrant?*

YesNo
Within 1 mile of the coast?*

YesNo
SECTION 5 - Liability & Risk Triggers

Required
Do you / tenants have any dogs?*

YesNoOther
Do you have any animals other than dogs?*

YesNo
If Yes, please describe.
Do you have a wood stove?*

YesNo

Swimming Pool*

YesNo
Above or In-ground?

Above GroundIn Ground

Do you have a trampoline?

YesNo
If Yes, do you have a net around it?

YesNo
Do you conduct any business in the home?*

YesNo
Type of In-Home Business
Section 6 - Coverage Snapshot

We calculate replacement cost and recommend coverage limits based on your home and risk profile. The questions below help us understand your current protection.
Current Liability Limit*

$100,000$300,000$500,000$1,000,000Not Sure
Personal Umbrella Policy?*

YesNoNot Sure
Deductible Preference*

Lower deductible / higher premiumBalancedHigher deductible / lower premiumNot Sure
Any high-value items needing special coverage?*

JewelryWatchesFine ArtFirearmsNoneNot Sure
SECTION 7 - Fit Alignment

When choosing insurance, what matters most to you?
How would you describe your approach to insurance planning?*

Lowest priceBalanced price and protectionLong-term protection and advisory guidance
SECTION 8 – Internal Use Only

Broker Submission Worksheet
Dwelling
Other Structures
Personal Property
Loss of Use
Liability
Medical Payments
Deductible
Broker Coverage Request – Page Insurance Standard Package

Please quote with the following coverage structure (or closest available equivalent):

• Replacement Cost – Dwelling
• Extended Replacement Cost – 25% or highest available up to 50%
• Replacement Cost – Personal Property
• Special Coverage form if available
• Ordinance & Law – 25%
• Water Backup – $10,000
• Equipment Breakdown – $25,000
• Identity Theft – $25,000
• Cyber – Included if available

If any endorsement differs materially, please note in quote response.

Please apply core limits and deductibles as listed above.
Notes
Should be Empty:

Rows	Yes	No
Prof Install
Inspected?
Cleaned Annually

Rows	Yes	No
Fenced
Diving Board
Slide

SECTION 1 - About You

SECTION 2 - Current Insurance & History

SECTION 3 - Property Overview

SECTION 4 - Construction & Systems

SECTION 5 - Liability & Risk Triggers

Section 6 - Coverage Snapshot

SECTION 7 - Fit Alignment

SECTION 8 – Internal Use Only