Homeowner's/Dwelling Quote

If you are interested in Condominium or Renter's Insurance, please click here.

*Fields marked in red are required*

Personal Information:

First Name		Last Name
Street Address
City		State
Zip
Primary Phone
Secondary Phone
Social Security #
E-mail
Do you currently have Homeowner's or Dwelling Insurance	Yes No
	If yes, how long have you had continuous coverage?	Years	Months
	Present insurance company
	Policy Number:
	When does your policy expire?		ex: 09/30/2005
	Any losses in the past 3 years?	No Yes If yes, how many?
		Please give the Date Amount Paid Briefly Describe
If no, why?	--Why were you cancelled-- Cancelled Non-Renewed Other
	If other, why?

Property Information:

Are you within 1000 feet of a fire hydrant?	--Please Select-- Yes No
Are you within 5 miles of a fire department?	--Please Select-- Yes No
Type of dwelling	--Please Select-- 1 Family 2 Family Townhouse
Is this dwelling your primary residence?	--Please Select-- Yes No
	If no, will this residence be rented out?	--Please Select-- Yes No
	If no, will this residence be rented out for seasonal purposes?	--Please Select-- Yes No
What is the construction type?	--Please Select-- Masonry (Brick) Frame
Year of construction
Square Footage		If you do not know the exact number, please complete this form and contact our office.
Heating Type	--Please Select-- Gas Electric Oil
	If oil, where is the tank located?	--Please Select-- Basement On Slab Underground
	Approximate age of tank
	If underground, is there a contracted oil tank service?	--Please Select-- Yes No
Wiring Type	--Please Select-- Circuit Fuses Knob & Tube
	Date of most recent updates
Plumbing	--Please Select-- Copper PVC
	Date of most recent updates
Roof	--Please Select-- Shingle Slate Other
	Date of most recent updates:
Do you have a burglar alarm?	--Please Select-- Yes No
Purchase Price
Is there a mortgage on the home	--Please Select-- Yes No
	If yes, what is the mortgage amount?

Dwelling Limit		May be different from market value (i.e. the actual cost to replace the wood, nails, ceiling, etc.)
Liability Limit	--Please Select-- Yes No
Medical Payment	--Please Select-- 1,000 2,000 3,000 4,000 5,000

Additional Information:

Any pets?	--Please Select-- Yes No
	If yes, how many?
	Please describe breed(s)
Do you have a swimming pool?	--Please Select-- Yes No
	If yes, above or below ground?	--Please Select-- Above Ground Below Ground
	Diving board?	--Please Select-- Yes No
Do you have a trampoline?	--Please Select-- Yes No