Homeowner's Insurance Quote Personal Information Current Homeowners Insurance Home Information Structure Information Features Additional Features Additions Hazards Additonal Comments Name Address City State Zip Code Day Phone Best Time To Call AM PM Email Address Occupation How Long At Your Current Job? Social Security Number # (This info is needed for the best and most accurate quote. Ballpark estimates are given without this info) Proceed Prior Coverage? YesNo Company Name (not agency) Policy Expiration Date Premium Amount Amount insured for $ Policy Type Primary Secondary Term 6 Months 1 Year Other New Purchase Yes No Back Proceed How Long At Present Address? Year Home Was Built? Square Footage (excluding garage and basement) Any Claims in Last 3 Years Date of Last Remodel or Upgrade Work Done Back Proceed Type 1 Story1 1/2 Story2 StorySplit LevelBi-levelOther Construction FrameStuccoVeneerMasonryOther Roof Type Asphalt ShingleWood ShingleTile / SlateOther Roof Age Foundation BasementCrawl spaceSlabOther Garage Type AttachedDetachedBasementBuilt-InCarportOther Garage Space 1 Car2 Car3 Car4 Car Back Proceed Bedrooms? Full Bathrooms? Half Bathrooms? Total Rooms Flooring Type Vinyl Tile or sheetCarpetCeramicHardwoodLaminate Alarm Type (Select All That Apply) CentralLocalFireBurglarMonitoredUnmonitoredSmoke Detectors Wall Height Wall Covering PaintTileWallpaperPaneling Ceilings PaintTileWallpaperPaneling % Cathedral Ceilings? Basement NoneFurnishedUnfurnished Basement SQFT Deck SQFT (if applicable) Porch SQFT (if applicable) Basement SQFT (if applicable) Screened Patio SQFT (if applicable) # of Chimneys (if applicable) # of Hearths (if applicable) Back Proceed Heating System NoneElectricGasOilPropaneSolarOther Central Air Yes Central Vac Yes Back Proceed Additions Fire PlaceHot TubJacuzzi Back Proceed Trampoline NoIf yes, is there a safety net installed?If yes, is there a fence surrounding it? Any Animals or Pets? Kind and breed. Any vicious animals or animal with bite history? YesNo Swimming Pool? (Select all that apply) NoIn GroundAbove GroundDiving BoardSlideFenceLocked gate Any body of water on the property (pond, bayou, lake...?) Do any residents smoke? Is the property located on more than 5 acres? Yes No If yes, does liability need to be extended? YesNo Any Business conducted on premises? YesNo Have you had a foreclosure, repossession, or bankruptcy in the past 5 years? Do you have any recreational vehicles? YesNo If yes, what kind and is there current coverage on it/them? Back Proceed 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. Back Send
