Homeowner Insurance Rate Quote

HOMEOWNER INSURANCE QUOTE REQUEST Please complete the following information if you would like to obtain a homeowner's insurance quote. Please understand this is not an application for insurance. An application will be sent to you if coverage is desired. All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you. Personal Information What is your name? Last First Middle What is your physical address? Street City State Select Alaska Alabama Arkansas Arizona California Colorado Connecticut Washington, DC Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Zip What is your mailing address if different? Street City State Select Alaska Alabama Arkansas Arizona California Colorado Connecticut Washington, DC Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Zip What is your e-mail address? E-mail What is your telephone number? Telephone What is your fax number? Fax What is the best time to call? Time to Call Do you currently have an insurance carrier? Carrier Yes No If you have a carrier, what is it? Name of Current Carrier If you have a carrier, what is the expiration date of your current coverage? Expiration Date Non Renewed? Non Renewed Yes No Amount of your mortgage? Mortgage Amount Is dwelling east or west of US1? US1 Select East West Is dwelling east or west of the intercoastal waterway? Waterway Select East West What type of residence? Residence Type Select Primary Seasonal Secondary What year was the residence built? Year Built How many square feet? Square Feet What is the amount of the dwelling coverage? Dwelling Coverage Number of bedrooms? Bedrooms Select 1 2 3 4 5 6 7 8 Number of bathrooms? Bathrooms Select 1 2 3 4 5 6 How many stories? Stories Select 1 2 3 4 What is the foundation? Foundation Select Slab Stilts Crawlspace What is the construction type? Construction Type Select Frame Masonry How many car garage? Garage Select 1 Car 2 Car 3 Car None What is the roof type? Roof Type Select Asphalt Shingle Clay Tile Concrete Tile Metal Wood Shingles Were storm shutters professionally installed? Storm Shutters Select Professionally Installed Not Professionally Installed Do Not Have Gated Community? Gated Community Yes No Is the alarm system manned for burglary? Burglar Alarm Yes No Is the alarm system manned for fire? Fire Alarm Yes No Is there a pool? Pool Yes No Does pool have screened or fenced enclosure? Pool Enclosure Select Screen Enclosure Fence Not Enclosed If pool has screened enclosure, is it under truss? Screen Enclosure Under Truss Select Yes No Not Applicable Do you have granite counter tops? Granite Counter Tops Yes No Do you have wood cabinets? Wood Cabinets Yes No Do you have a dog? Dog Yes No If you have a dog, what kind is it? Dog Breed What is the distance to the nearest fire station? Fire Station Distance What is the distance to the fire hydrant? Fire Hydrant Distance Do you need flood insurance? Flood Insurance Yes No Do you need auto insurance? Auto Insurance Yes No Do you need mortgage insurance? Mortgage Insurance Yes No