HOMEOWNER QUOTE

This form is for an estimation of premiums only, and results will be based soley on the information you provide. For the best quote be as accurate as possible. -Thank You-

FIRST NAME *

LAST NAME *

MIDDLE INITIAL *

Address, City, and Zip Code of the Property Insuring *

DATE OF BIRTH *

OCCUPATION

MARITAL STATUS * MARRIEDSINGLEDIVORCEDWIDOWED

IF MARRIED, LIST YOUR SPOUSES FIRST, LAST NAME, DOB. (SSN OPTIONAL)

ABOUT THE HOME

YEAR BUILT *

Has the Roof and AC unit been replaced in the last 20 years? * YesNoI don't know

YEAR ELECTRIC WAS LAST UPDATED *

NUMBER OF BEDROOMS *

NUMBER OF BATHROOMS *

THE GARAGE IS: * ATTACHEDDETACHEDNO GARAGE ONLY A CARPORTNO GARAGE NO CARPORT

HOW MANY SQUARE FEET DOES THE HOUSE HAVE? *

THE PLUMBING WAS LAST UPDATED ON (DATE): *

THE HEAT IS: GASELECTRIC

DO YOU HAVE CENTRAL HEAT AND AIR? * YESNO

IS THERE ANY OTHER TYPE OF HEATING DEVICE IN THE HOME? IF YES, LIST TYPE *

IF YOU HAVE A SPACE HEATER LIST IT HERE

ARE THERE ANY DOGS ON THE PREMISES? IF YES, WHAT BREED? HAVE THEY EVER BITTEN ANYONE? *

IS THERE A BUSINESS ON THE PREMISES? IF YES, WHAT TYPE? *

WHAT IS THE HOME'S APPRAISED VALUE? *

WHAT WAS THE HOME'S PURCHASE PRICE, AND WHAT YEAR DID YOU PURCHASE IT?

HOW MUCH COVERAGE WOULD YOU LIKE ON YOUR HOME? *

HOW MUCH LIABILITY COVERAGE DO YOU NEED? *

WHAT IS YOUR DESIRED DEDUCTIBLE?

THIS HOME IS: * VACANT BUT I WILL OCCUPY IT MYSELF LATERI OCCUPY ITI RENT IT OUTVACANT

LIST ANY ADDITIONAL INFORMATION YOU FEEL NECESSARY TO OBTAIN A QUOTE

PHONE *

EMAIL *

YOUR PREFERRED METHOD OF CONTACT REGARDING YOUR QUOTE: * PHONEEMAILU.S MAIL

HOW DID YOU HEAR ABOUT US? * POST CARDYAHOO SEARCH ENGINEGOOGLE SEARCH ENGINECUSTOMER REFERRALI'M A CURRENT CUSTOMERTHE FEIST PHONE BOOKTHE USER FRIENDLY PHONE BOOK

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