Home Insurance Quote Request
Sutton Insurance, Inc.
Your Name:
*
First Name
Last Name
Date of Birth:
Name of Spouse:
First Name
Last Name
Date of Birth of Spouse:
Marital Status:
Single
Married
Email:
*
example@example.com
Home Phone:
-
Area Code
Phone Number
Work Phone:
-
Area Code
Phone Number
Cell Phone:
-
Area Code
Phone Number
Current Mailing Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Present Insurance Company:
Current Policy Expiration Date:
Is the location to be insured the same as above "Current Mailing Address"?
Yes
No
If no, please include address below:
Do you Own or Rent?
Own
Rent
Is this property:
Primary
Secondary
Rented
Vacation Rental
Vacant
Any claims in the last 5 years?
Yes
No
If yes, please explain:
Is the property:
House
Condominium
Townhouse
Mobile Home
Apartment
If apartment, number of units:
What is the construction?
Frame
Masonry
Stucco
Other
# of stories:
Square footage:
Last Updates:
Rows
Roof
Plumbing
Heating
Electrical
Date of Update:
Roof Type:
Heating Type:
Is the electrical service circuit breakers or fuses?
Is it 100 or 200 AMP
# of families in home:
Year built:
Responding Fire Dept:
Miles from Fire Dept:
Is the house with in 1000 ft of a fire hydrant?
Yes
No
Wood burning stove/furnace in house?
Yes
No
or Outdoor Wood Stove?
Yes
No
If Outdoor Wood Stove, how many feet from any structure?
Any wood heat in any detached structures such as a garage?
Yes
No
Any pets?
Yes
No
Do you own a trampoline?
Yes
No
Do you own a pool?
Yes
No
If yes to pool, is it:
In Ground
Above Ground
Is there a basement under entire house?
Yes
No
If yes, is it:
Finished
Unfinished
If finished, what % finished?
How many acres of land do you have?
Are any rented out for farming/hunting?
Yes
No
Any farm buildings?
Yes
No
Home Insurance Value $
Renters Contents Coverage $
Deductible:
100
250
500
1000
2000
2500
5000
Liability:
100,000
300,000
500,00
1,000,000
Med Pay:
500
1000
2000
3000
5000
10000
25000
Other Structures Limit
Personal Property Limit
Any business exposures at your property?
Yes
No
Do you want any items schedule on policy? (ex: guns, jewelry, fine arts)
Does current policy have any extra coverages such as: water/sewer backup, equipment breakdown, service line coverage, earthquake, flood, farm liability, identity theft, other?
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