Homeowners Quote Response Form

Name     
Street   
City     
State    
Zip Code  

Telephone Fax email
Best time to call

Quote for: Homeowner Tenant Condominium

Coverages

Dwelling Other Structures Personal Property Loss of Use

Personal Liability 100,000 300,000 500,000 1,000,000 Medical Payments 1,000 2,000 5,000 10,000 Deductible 100 250 500 1,000 2,500

Information About Your Home:

Type of construction wood frame brick/masonry Year built Number of families Smoke detectors Yes No Burgular Alarm Yes No Swimming pool Yes No Wood stove Yes No Dog Yes No
Type of dog Any smoker in the house? Yes No

Year of the updates in your home: Wiring , Plumbing , Roof , Heating

Have you filed a homeowners claim in the last 10 years? No Yes

If so, please list date, type of claim, and amount paid to you.

Current company Current agent Renewal date Premium

 

Please enter any additional comments regarding our products or services:

Thank you for taking the time to answer the questions in our survey.

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