Home Insurance Quote Request
Please be aware of how we quote home insurance: We collect all the necessary information from you in order to determine the correct rating for you. We then use that information in order to determine an estimate for your insurance. Some of the things we may input include your name, date of birth, and your social security number (we will not ask you for this online-- but you will be asked for it when you apply for your policy). This information is used to pull a record of your claims history, and insurance/credit score. If you have questions or concerns about this please call us before filling in the quote request below at (405)805-0005. By completing the information below you are providing us permission to pull your reports. Please note, we do not pull your claims record during the quote process, we only pull your claims record after you agree to purchase the policy. If you have had homeowner claims please provide detailed info about your claims history so we can match you with the best carrier for your situation.

Don't want to type all this stuff? Just give us a call at (405)805-0005 and we will quote you right over the phone! We have "real" humans, right here in Oklahoma standing by to help you with your insurance needs!


We do not re-sell your information


* Means we must have this information in order to quote you accurately

Is this quote for a home you already own, or one you will be purchasing? *
Approximately what month/year did you originally purchase (or closing date for new home purchase)?
enter the month and year purchased
Your answer
Do you currently have home insurance? *
If you answered YES above, what company are you with?
Enter the name of the insurance carrier
Your answer
...and how long have you been with the current carrier?
If you answered YES above, when does your current policy expire?
enter the expiration date
MM
/
DD
/
YYYY
Have you had any home or renters claims in the past 5 years? *
If YES, how many claims? Please tell us the cause of the claim, month/year of claim, and the approximate amount:
If you have had claims please provide as much information as possible so we may match you with the best carrier.
Your answer
Is your home? *
How many stories tall is your home? *
How many square feet is your home?
Your answer
What kind of foundation does your home have?
Is your home in a high hazard flood area?
Is your home on MORE than 5 acres?
Does your home have central air conditioning?
Number of fireplaces:
Original Year home was built?
Your answer
Any carports?
Do you have a garage?
If you have a garage how many cars?
If you have a garage is it:
What is the exterior of your home primarily made of?
If exterior is "other" please explain:
Your answer
What kind of roof does your home have?
If "other" or a mixture of materials please explain:
Your answer
Is your roof certified "hail resistant"?
Documentation is required for discount
VERY IMPORTANT: What year was your current roof installed?
Your answer
Bathrooms
Number of Full Baths
(Full Bath = toilet, sink, shower/bath tub)
Number of Half Baths
(Toilet & Sink)
Number of 3/4 Baths:
(3/4 bath = Toilet, sink, and shower )
Other Information
Do you have any of the following:
If you have dogs or livestock please describe below what breeds and how many:
Your answer
Do you have any of the following:
(check all that apply)
First Named Insured
First Name *
(as it appears on deed)
Your answer
Last Name: *
(As it appears on Deed)
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Marital Status
Gender *
Highest level of Education completed:
Some carriers discount based on the level of education
If you are employed, what is your occupation?
Some carriers discount for occupations
Your answer
Spouse / Co-owner Information
If you are single and the only property owner in the household please scroll own to the "Your Contact Information" section below. If you are married you must include your spouse's information.
How is this person related to the Primary owner?
Marital Status Spouse / Co - Owner
Spouse/Co-owner Date of Birth
MM
/
DD
/
YYYY
Gender - Spouse/ Co- owner
Spouse / Co-owner as their name appears on the deed:
Include first and last name
Your answer
Spouse / Co-owner occupation.
Some carriers discount for occupations
Your answer
Spouse / Co-owner Highest level of Education completed:
Some carriers discount based on the level of education
Address of the Home you wish to Insure
Street *
Your answer
City *
Your answer
State
Your answer
Zip Code *
Your answer
Servicing Fire Department
(If you do not know... put "don't know"
Your answer
How many miles from fire station
Your answer
Approximate feet from fire hydrant:
Approximate amount you wish to insure the primary dwelling for:
Your answer
Do you have any outbuildings on the property? If so, what do you have and how much insurance coverage do you wish to carry o them?
Your answer
If you have not moved to the address above yet, or you have a separate mailing address please provide your mailing address:
Your answer
Please provide your email address so we may email your quote to you: *
Your answer
Please provide your phone number in case we have additional questions:
Your answer
ADDITIONAL INFORMATION or comments you wish to provide:
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service