Homeowners insurance comes in many different types and carriers.  At our agency, we provide multiple carrier solutions with options to meet your budget and coverage needs.  Knowing where to start means that we need to gather information.

Please start with the following form knowing the following:

• We sell and provide home insurance.  We do NOT sell leads.  All information is kept in our office and does not get shared with others.
• We do not ask for Social Security numbers.
• Relationships work best when providing coverage.  The submittal will start our process of providing prices.  We will call you… Our desire is to work with you.  The below will start the process.
  Online Quote

  1. First Owner's First & Last Name(required)
  2. Please Choose Choose Male Female
  3. First Owner's Birth Date
  4. Email(valid email required)
  5. Phone Number
  6. Second Owner's First Name & Last Name
  7. Please Choose Choose Male Female
  8. Second Owner's Birth Date
  9. Relationship Married Parent/Child Friend Domestic Partner Other
  10. Current Mailing Address
  11. Current City
  12. Current State
  13. Current Zip
  14. Do You Currently have Property Insurance? Renters Insurance Home Insurance Condo Insurance Mobile Home Insurance Other NONE

  Information on the Home to be Insured

  1. Address to be Insured
  2. City
  3. State
  4. Zip
  5. County
  6. What type of Occupancy? Primary Residence Secondary Residence Tenant Occupied Vacant Home Vacation Short Term Rental Other
  7. Type of home Single Family Cluster Home Condo Duplex Triplex Quadraplex Townhome
  8. Exterior Construction Wood Exterior Vinyl/Aluminum Brick Vaneer Stucco Log Hardi Plank Solid Brick or Concrete Walls
  9. Type of Foundation Slab Crawl Space Basement- 0% Complete Basement- 25% Complete Basement- 50% Complete Basement- 75% Complete Basement- 100% Complete
  10. Garage Type Attached to Home Detached from Home In Basement Carport Driveway Only
  11. Garage/Carport Size 1 Car 2 Car 3 Car 4 Car None
  12. Is There Heated Living Space Above the Garage?
  13. Yes No
  14. How Many Stories is the Home (not including basement) Please Choose Ranch-1 story Two Story Three Story Bi-Level Tri-Level Split Level
  15. Approximate Number of Square Feet (not including basement)
  16. Year Built
  17. Fire Places NONE 1 2 3 4 5 6
  18. How Many Full Bathrooms? 1 2 3 4 5 6 7 8 9 10
  19. How Many Half Bathrooms? 0 1 2 3 4 5

  Current or Competative Coverage

  1. Dwelling Coverage
  2. Personal Property
  3. Liability Coverage $100,000 $200,000 $300,000 $500,000 $1,000,000
  4. Medical Coverage $1,000 $3,000 $5,000

  Discounts

  1. Deadbolt Locks, Smoke Detectors, Fire Extinguisher?
  2. Yes No
  3. Monitored Security System/Fire Alarm? None Monitored Alarm/Fire Non-Monitored Alarm/Fire
  4. Interior Fire Sprinkler System
  5. Yes No

  Other

  1. Does the home have a Mortgage?
  2. 1st Mortgage
     2nd Mortgage
     3rd Mortgage
  3. Does your Subdivision have a Mandated Homeowner Association?
  4. Yes No
  5. Re-Key Coverage Desired? (Lost/Stolen Keys)
  6. Yes No
  7. Identity Theft Coverage Desired?
  8. Yes No
  9. Business Computers/Equipment Coverage
  10. Yes No
  11. Comments
  12. Validation
  13. As part of the application process, we may collect personal information from persons other than you or other individuals proposed for coverage, including credit reports and loss information reports. This information, as well as other personal or privileged information subsequently collected by us, may in certain circumstances be disclosed to third parties without your authorization. You have a right of access and correction with respect to all personal information we collect. If you would like more detailed information in writing about our information collection practices, please let us know. NOTE: In regard to the statement above, we are required to post this as a process of obtaining Loss Information History and final quoting criteria. Submitting this form approves the collection of data. We have not asked for and do not require a social security number in this process.
  14. I Agree

   

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