Free Homeowners Insurance Quote

Personal Information

Last Name:

First Name:

Middle Name:

Address:

City:

State:

Zip:

Home Phone:

Work Phone:

Fax Number:

Email Address:

Date of Birth:

Property Information

Property Address:

City:

State:

Zip:

What is the dwelling type: Select Homeowners Townhome/Condo Renters

Dwelling value:

Is the property occupied: Select Owner Tenant Both Owner/Tenant

What year was it built:

Date purchased:

Construction type: Select Brick Stone Frame Masonry Superior Log Cabin Frame-Stucco Masonry Veneer Asbestos Shingle

How many stories: Select 1 1 1/2 2 2 1/2 3

How many Units:

If two stories, what is the ground floor square footage:

What is the total square footage of the building:

What is the property's topography: Select Flat Land Gentle Hillside Next To A Cliff Terraced (Sloped) On A Hill Under 15% On A Hill 16-30% On A Steep Hill Over 30%

Foundation type: Select Crawl space Piers/Pilings/Stilts Slab on grade Unfinished basement Walkout basement Wood foundation basement

Garage type: Select No Carport - Garage 1 Car Carport - Attached 2 Car Carport - Attached 1-4 Car Carport - Detached 5 or More Car Carport - Detached 1-4 Car Garage - Attached 5 or More Car Garage - Attached

Roof type: Select Architectural shingles Asphalt/Fiberglass shingles Built-up/Tar and gravel Clay tile Concrete tile Corrugated steel Mineral fiber shakes Mission Tile Rock roof Roll roofing Rubber roof Slate Tin Wood fiber shingles Wood shake

Was the roof updated:YesNo

If yes, what year:

Does the building have a pool:YesNo

If there is a pool, is it fenced:YesNo

If there is a pool, is there a lockable fence:YesNo

If there is a pool, is there a diving board:YesNo

If there is a pool, is there a slide?:YesNo

Is the building in the brush:YesNo

Is there a brush hazard within one mile of the building:YesNo

If yes, has the brush been cleared by 250 feet from all sides of the building:YesNo

Is there a smoke alarm:YesNo

Is there a fire extinguisher:YesNo

Are there deadbolts:YesNo

Are there circuit breakers:YesNo

Does the electrical circuit box have copper wiring:YesNo

Do you have central air:YesNo

How old is the heating / air conditioning:

Is the heating / air conditioning thermostatically controlled:YesNo

Has the plumbing been updated:YesNo

Is the plumbing copper:YesNo

Does the building have interior automatic fire sprinklers:YesNo

Is there a theft alarm:YesNo

Is there a fire alarm:YesNo

Are the alarms monitored:YesNo

What is the earthquake zone:

Has it been earthquake retrofitted: Select Not Required, Home Built After 1975 Yes, Recently Bolted-Retrofitted for EQ No

What is the fire district:

Do you have a trampoline:YesNo

Are there dogs on the property:YesNo

If yes, how many and what is the breed of each dog:

Are there any other pets or animals on the property:YesNo

If yes, how many and what is the description of each:

Current Coverage Information

Current Insurance Company: Select 20th Century 21st Century Casualty AAA AEGIS AETNA A G Edwards AIG Alliance Allied Allstate American Family Insurance American Manufacturers Mutual American National General Amica Mutual Blue Cross Calfarm Charter Insurance CIGNA Civil Service Employees Clarendon National CNA Colonial Penn Company Not Listed Continental Country Companies Dairyland Don't know name Electric Farm Bureau Insurance Farmers Farmers Union Fidelity Guaranty Fireman's Fund First General GEICO Casualty Co. General Accident Grange Ins Assn Guaranty National Hanover Hartford Horace Mann John Hancock Kemper Liberty Mutual Lumbermans Mutual Metropolitan Insurance Midwest Security Millers Mutual Fire Mutual of Omaha Mutual of New York National Farm Bureau National General Nationwide New York Life Northwestern Pacific Pennsylvania General Progressive Providian Prudential Rural Insurance SAFECO Sentry Shelter State Farm Travelers Unigard USAA Viking Workmens Company Not Listed Don't know name

What is the expiration date of the current policy:

Where there any losses or claims in the last 5 years:YesNo

If yes, what is the date, amount paid and description of each loss or claim:

Desired Coverage Information

Dwelling Amount:

Other Structures:

Personal Property:

Loss of Use:

Premise Liability: Select $100,000 $300,000 $500,000

Policy Deductible: Select 100 250 500 750 1000 2500 5000

Medical Payments: Select 1000 2000 3000 4000 5000

If earthquake insurance is requested, select deductible percentage %: Select No Earthquake Coverage 10% 15% 20% 25% 30%

Do you want building replacement cost coverage:YesNo

Do you want contents replacement cost coverage:YesNo

Questions or Comments:

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