Homeowners Quote Form

Although our agency feels it is important to personally speak with you and evaluate your insurance needs, we also understand your needs for convenience and timeliness.  In order to provide you with a quote, our agency needs you to complete the following form.  Please feel free to contact us with any questions or if you desire more personalized attention. 

Please provide the following contact information.  List the address of the home to be insured:        

Name
Street Address
Address (cont.)
City
State
Zip
County
Township/Boro
Work Phone
Home Phone
FAX
E-mail

How long have you lived at this address: 
    If less than 1 year, please list your prior address: 
If this is not your primary home or is intended for rental, please explain:  

Please fill in the limits of coverage you would like:

Please describe with as much detail as possible any additional structures on the premises below.  List the value and whether this is replacement value or actual cash value. (ex. Garage, Shed, Barn, Pool, Rental Dwelling....):

Please list any special items along with their value you would like to have scheduled on the policy:
    (Ex. Jewelry, Furs, Silverware, Art, Guns, Misc. Valuable Property....) 

Please provide as much information as possible about your home:

    What year was the home built? 
    What is the primary construction of the home (more than 50%)?  Brick Stone Stucco Vinyl or Aluminum Siding Wood Siding Unknown Siding Log Home
    Do you have any alarm systems in your home (including smoke).  Yes     No
        If yes, please describe: 
    Do you have a wood burning stove or insert in your home?  Yes     No
    Is the home under construction or vacant?  Yes     No
        If yes, when will it be completed or occupied: 
    Number of stories & square feet of home: 
    Number of bathrooms: 
    Basement:  None Finished Partially Finished Unfinished
    Do you have any animals or pets on the premises?  Yes     No
        If yes, please describe (list the breed of any dogs): 
         
    Do you operate a business out of your home or have a business related office?  Yes     No
        If yes, please explain:
         
    Does the home have a flat roof?  Yes     No
    If the home is over 20 years old:
        Has the roof been updated and when?
        Describe electrical service (ex. Breakers, Fuses, Updated Wiring, etc..)
       

Describe all homeowners related insurance claims/losses in the last 5 years. Please list date of loss.
(If none, please state "None"):

Please list any additional comments below which you feel may influence your insurance quote:

By submitting this information to our agency for a quote, you understand there is no coverage in force.  You also understand there may be additional information needed in order to secure a quote and we will contact you for this information.

After submitting the form for us to review, we will generally respond within 24 hours.  Please let us know how you would like us to contact you:  E-mail  Phone  Fax  US Mail