| Is
this insurance quote for Homeowners Renters |
Do you currently
have home Insurance?
Yes
No * |
|
If "Yes", when does your current policy expire? |
| If
"Yes", who are you currently insured with? |
|
If "Yes", how much is your home insured for? |
|
Year Purchased (if home) |
|
Purchase Price (if home) |
|
Loan Amount (if home) |
|
Monthly Rent (if rental) |
|
Approximate Interior Square Footage |
|
Approximate Year Built |
Is
your home located within 500 feet of a
fire hydrant?
Yes
No |
Is
your home located within 5 miles of a
fire station?
Yes
No |
Is
your home susceptible to flooding or high
water?
Yes
No |
Is
your home built on a hillside?
Yes
No |
Is
your area prone to landslides and/or sinkholes?
Yes
No |
Is
your home located within a brush hazard
area?
Yes
No |
Do
you have a dog?
Yes
No |
|
If "Yes", how many dogs do you have? |
|
If "Yes", what breed(s) is the dog(s)? |
Are
there any firearms in your home?
Yes
No |
Is
there a central alarm system?
Yes
No
|
Have
you experienced any losses or filed any
claims within the last 5 years?
Yes
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
 |
| Details |
| When would
you like to be contacted?
Morning
Afternoon
Evening
Any Time
|
Any
Comments / Questions?
|
