HOMEOWNERS  INSURANCE  QUOTE We would like to provide you with a free, no-obligation homeowners insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only. Personal Information Name: Address: City:   State:   Zip: Day Phone:   Night Phone: Best Time To Call:   AM   PM Email Address: Occupation:   How Long At Current Job: Current Homeowners Insurance Information Company Name (not agency): Policy Expiration Date:   Premium Amount: $ Amount Insured For: $     Policy Type: Primary Secondary Term: 6 Months   1 Year   Other: Home Information How Long At Present Address:     Year Home Was Built: Sq. Footage (excluding garage and basement): sq. ft.         # of Claims In Last 3 Years: Structure Information Type Construction Roof Foundation Garage 1 Story 1 1/2 Story 2 Story Split Level Bi-Level Other Frame Stucco Veneer Masonry Other Asphalt Shingle Wood Shingle Tile or Slate Other Basement Crawl Space Slab Other 1 Car 2 Car 3 Car 4 Car None Age of roof: yrs. Attached Detached Basement Built-in Car Port None Features Bathrooms Basement Deck/Porch/Patio Fireplaces # of Full: # of Half: None Finished Unfinished Sq. Ft.: Deck Sq. Ft.:     Porch Sq. Ft.:     Screened Patio Sq. Ft.:     # of Chimneys:     # of Hearths:     Additional Features Heating System Central Air Central Vac Security Alarm Fire Alarm Smoke Detector None Electric Gas Oil Propane Solar Other Yes Yes None Monitored Not Monitored None Monitored Not Monitored Yes Scheduled Personal Property Please indicate additional property that is not listed in boxes 10-14 # Property Amount of Ins. # Property Amount of Ins.   1 Jewelry $ 8 Coins $ 2 Furs $ 9 Golfer's Equipment $ 3 Fine Arts $ 10 $ 4 Cameras $ 11 $ 5 Musical Instruments $ 12 $ 6 Silverware $ 13 $ 7 Stamps $ 14 $ Unattended Car Coverage (Stamps/Coins) Broad Form Pair & Set Coverage Non-Mobile Organ Coverage Safe Credit (Identify Property, Safe Class, Etc)   ACV Loss Settlement Replacement Cost Loss Settlement Breakage Coverage (*On Schedule) Blanket Coverage Additional Rating Information Additional Comments Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter them here. Please click on the "Submit Quote" button to send your quote request. One of our representatives will respond to your submission as soon as possible.