| This
insurance quote is 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
1,000 feet of a fire hydrant?
Yes No |
Is your home located within
5 miles of a fire station?
Yes No |
Is your home is 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 |
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 |
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| Details |
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When would you like to be contacted?
Morning
Afternoon
Evening
Any
Time
|
Any Comments / Questions?
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