HOME QUOTE
Personal Information
Name:
*
Address:
*
(street address of house)
Address 2:
*
(apartment or suite)
City:
*
State:
*
Iowa
Illinois
Minnesota
Nebraska
Zip:
*
County:
*
Additional Information
Home Phone:
*
Work Phone:
Cell Phone:
Best place to call:
Home
Business
E-mail:
*
Occupation:
How long at current job:
Current Homeowners Insurance Information
Company Name (not agency):
Policy Expiration Date
Premium Amount: $
Home Type:
Primary
Secondary
Amount Insured For: $
Purchase Price: $
Loan Amount: $
Quote Request
Coverage on House: $
Deductible: $
500
1,000
Liability Limit: $
300,000
500,000
1,000,000
Home Information
Business in the home?
none
Daycare
Office
Shop
Other
If Other:
Year Built
# of Families:
1 to 2
3 to 4
more than 4
Structure Information
Type:
1 Story
1&1/2 Story
2 Story
Split Level
Bi-Level
Other
Roof:
Asphalt Shingle
Wood
Tile or Slate
Other
Age of roof in years:
Construction:
Frame
Stucco
Masonry
Veneer
Other
Foundation:
Basement
Crawl Space
Slab
Other
Square Footage:
(Main Floor)
Garage:
1 Car
2 Car
3 Car
4 Car
Other
none
Attached
Dettached
Basement
Built-In
Car Port
None
Heating System:
None
Electric
Natural Gas
Propane
Oil
Solar
Other
Central Air
Yes
No
Central Vac
Yes
No
Swimming Pool
Yes
No
Wood Stove
Yes
No
Within City Limits
Yes
No
Scheduled Property
Dwelling Protection
(check all that apply)
Jewelry: $
Guns: $
Furs: $
Fine Arts: $
Cameras: $
Golf Equipment:$
Other:
Smoke Detectors:
Yes
No
Extinguishers:
Yes
No
Central Alarm:
Yes
No
Dead Bolt Locks:
Yes
No
Fire Hydrant
Unknown
Less than 1000 ft.
Greater than 1000 ft.
Fire Station
Unknown
Less than 5 miles
Greater than 5 miles
Claim History — Last 5 years
Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter it here.
This is a request for quotation only. A licensed agent will respond.