Homeowners Insurance Quotation Form
One Simple Form - takes only 2-3 Minutes! Your Personal Data:
Your Name:
Property Address:
City:
Your "County" is?
State: (Must be Georgia)
Zip/Postal:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
Dwelling Information
Year Home Built:
Home Square footage:
Is this Builder's Risk? (new home constr.)
NO
YES
Month/Year home to be complete:
Number of units:
1 family
Duplex
Type foundation:
Slab
Crawlspace over
slab
Pier & Post Other
(list in remarks)
Type Construction:
Frame
Brick/Veneer
Stone Other
(list in remarks)
Type Roof:
Shingle
Wood Shake
Tar/Gravel Spanish Tile
Metal Other
Number of stories:
One
1.5
Two Three
Do you own animals or pets?
Yes
No
If yes, list type/for dogs, list breed:
Are You Near Brush Area?
Yes
No
# of feet to nearest fire hydrant:
# of miles to nearest fire station:
Does Home Have a Garage?
Yes
No
Tell whether built in, detached/attached, and how many cars?
Currently Insured?
Yes
No
Name of Carrier & how long insured?
Prior Claims?
Yes
No
Describe claims in detail:
Rate Your Credit History and Past Insurance Payment History:
(Some companies products are based on your credit and payment history.)
Excellent Fair
Poor Horrible
Primary Policyholder's Birthdate:
(Some companies products offer discounts for certain age groups.)
Plumbing type:
Copper
Galvanized
Mixed (Copper/Galvanized)
Heating Type:
Gas (Propane or natural)
Electric
Oil (if oil, list tank location in remarks)
Circuit Breakers or fuses?
Breakers
Fuses
# Bedrooms:
# Bathrooms:
# Fireplaces:
#
Chimneys:
Special
features (i.e., deck, air
conditioning, alarm systems, pool, etc.)
Coverages:
Dwelling Cov. $
Contents $
Liability Cov. $
Deductible $ ($250, $500, $1,000, etc.)
Comments/Remarks (describe any scheduled jewelry, in-home
business, oil tank location, or other special coverages/remarks here):
Send my quotation via:
E-Mail Fax Regular Mail
Call Me By Phone
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COMPLETELY!
We value your input as PRIVATE information. Every step has been
taken to insure your privacy, security, and our intent is to release quote information only
to you. We will not give your data to ANY other person or group for sales, marketing,
or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to
release us from any liability should this information be accidentally viewed by others.
Our intention is to maintain your complete privacy.
Yes, I Agree.
Please Send Me a Quote NOW!
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