Richard Brown Insurance
58 W Vincennes St
Linton, IN 47441
www.richardbrowninsurance.com
(812) 847-4798
Customer Details:
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Social Security Number
*
Drivers License Number
Marital Status
*
Spouse's Name (if applicable)
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Social Security Number
Drivers License Number
Relationship
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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E-mail
example@example.com
How did you hear about us?
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Family
Friend
Business Card
Facebook
Website
Advertisement
Other
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Home Insurance Questionnaire
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Year Home was Built
*
Square Feet
*
How many stories?
*
Type of Heating
*
Does your home have Central Air?
*
Please Select
Yes
No
Do you have a mortgage?
*
Who is your mortgage with?
Does your home have any of the following?
*
Burglar Alarm
Fire Alarm
Smoke Alarm
Fire Extinguishers
Permanently-Attached Backup Generator
Deadbolts
Do you have a pool?
*
Please Select
Above Ground Pool
In Ground Pool
No Pool
Is the pool fenced?
*
Please Select
Yes
No
N/A
Do you have a trampoline?
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Please Select
Yes
No
Does trampoline have netting?
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Please Select
Yes
No
N/A
What type of foundation do you have?
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Please Select
Crawl Space
Slab
Basement
Other
If other, please specify.
If basement, is it finished?
Please Select
Yes
No
If basement, do you have a sump pump?
Please Select
Yes
No
How many bathrooms?
*
Woodstove or Fireplace?
*
Please Select
Woodstove
Fireplace
None
What type of roof do you have?
*
When was it last replaced?
*
Do you have a garage? (Attached, Detached, How many cars?)
*
What insurance company is your home currently insured with?
*
What is your current home insurance premium?
Is there anything else you would like for us to know about you or your home?
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Is there any other type of quote that you would like to see or anything else that you would like to let us know?
What agent would you like to work with?
Please Select
Joyce Axsom
Audrey Sparks
Allie Walton
No Preference
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