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Home Quote Form
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Name
Your answer
Phone Number
Your answer
Date of Birth
MM
/
DD
/
YYYY
Is there anyone else named on the deed? If so, what is their name and date of birth?
Your answer
What is your marital status?
Married
Single
Widowed
Divorced
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What is the address of the property?
Your answer
Mailing address
Your answer
Is this a rental property?
Yes
No
Other:
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How long have you lived at this address?
*
Your answer
If less than 3 years, what is your prior address?
*
Your answer
Year built
Your answer
How many stories is the home?
1 story
2 story
Other:
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Square footage
Your answer
Type of roof
Shingle
Metal
Other:
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Roof year
Your answer
Is there an attached garage? if so, how many cars?
Your answer
Is there a detached garage? If so what size and what would you value it at?
Your answer
Do you have any covered, enclosed, or open porches? If so, what size?
Your answer
Exterior make of the home?
Brick
Vinyl
Other:
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What type of foundation do you have?
Crawlspace
Basement
Concrete Slab
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Number of bathrooms
Your answer
Primary Flooring?
Hardwood
Carpet
Vinyl
Other:
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Primary heat/cooling:
Electric
Gas
Other:
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Who is your insurance currently with?
Your answer
How long have you been insured with current company?
Your answer
Have you had any claims in the past 5 years?
Your answer
Do you have flood or sewer/drain backup coverage? Are you interested in adding it?
*
Yes
No
Do you have earthquake coverage? Are you interested in adding it?
*
Yes
No
Is there a mortgage on the property?
Yes
No
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Do you farm at this location?
Yes
No
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If yes, how many acres? What type of farming operations?
Your answer
Do you lease the ground? If so, what for?
Your answer
Billing:
Monthly
Quarterly
Semi - Annual
Annually
Escrowed
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Do you have a swimming pool?
Yes
No
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Do you own any dogs? If so, what breed?
Your answer
If there are any special additions to your home please detail them below.
Your answer
How did you hear about us?
Your answer
Due to underwriting standards, it is required that an agent come out and take pictures of the condition of the dwelling prior to producing a quote. The agent will ONLY be taking pictures of the exterior of the dwelling on the property. Confirmation of the condition of the dwelling is required in order for us to provide a quote.
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