Homeowners Quote Form

Please tell us more about your current or recent insurance policy. Be as accurate as possible.

Select your most current insurance company?
(You won't receive a quote from this company) ------Top 20 Insurance Companies------ AAA Insurance Co. AIG AIU Insurance Allied American Family Insurance Amica Insurance Clarendon National Insurance Country Insurance and Financial Services Erie Insurance Group Farm Bureau/Farm Family/Rural Farmers Insurance Liberty Mutual Insurance Metropolitan Insurance Co. Nationwide General Insurance Prudential Insurance Co. SAFECO Shelter Insurance Co. State Farm Insurance Co. Travelers Insurance Company USAA Casualty Insurance ---Alphabetical Listing of all Insurance Companies--- Company Not Listed AAA Insurance Co. AETNA AIG AIU Insurance Alliance for Affordable Services Allied Allstate County Mutual Allstate Indemnity Allstate Insurance American Alliance Insurance American Automobile Insurance American Casualty American Deposit Insurance American Direct Business Insurance American Empire Insurance American Family Insurance American Family Mutual American Financial American Home Assurance American Insurance American International Ins American International Pacific American International South American Manufacturers American Mayflower Insurance American Motorists Insurance American National Insurance American Premier Insurance American Protection Insurance American Service Insurance American Skyline Insurance Company American Spirit Insurance American Standard Insurance - OH American Standard Insurance - WI Amica Insurance Arbella Associated Indemnity Atlanta Casualty Atlantic Indemnity Blue Cross and Blue Shield Cal Farm Insurance California State Automobile Association Chubb Clarendon American Insurance Clarendon National Insurance CNA Colonial Insurance Continental Casualty Continental Divide Insurance Continental Insurance Cotton States Insurance Country Insurance and Financial Services Dairyland County Mutual Co of TX Dairyland Insurance Electric Insurance Erie Insurance Company Erie Insurance Exchange Erie Insurance Group Erie Insurance Property and Casualty Farm Bureau/Farm Family/Rural Farmers Insurance Farmers Insurance Exchange Farmers TX County Mutual Fire and Casualty Insurance Co of CT Fireman's Fund Geico Casualty Geico General Insurance Geico Indemnity Golden Rule Insurance Government Employees Insurance Guaranty National Insurance Hanover Lloyd's Insurance Company Hartford Accident and Indemnity Hartford Casualty Insurance Hartford Fire Insurance Hartford Insurance Co of Illinois Hartford Insurance Co of the Southeast Hartford Omni Hartford Underwriters Insurance Health Plus of America IFA Auto Insurance IGF Insurance Infinity Insurance Infinity National Insurance Infinity Select Insurance Integon Kaiser Foundation Health Plan Kemper Lloyds Insurance Landmark American Insurance Leader National Insurance Leader Preferred Insurance Leader Specialty Insurance Liberty Insurance Corp Liberty Mutual Fire Insurance Liberty Mutual Insurance Liberty Northwest Insurance Lumbermens Mutual Mass Mutual Mega Life and Health Ins. Metropolitan Insurance Co. Mid Century Insurance Mid-Continent Casualty Middlesex Insurance MSI Insurance Mutual of New York Mutual Of Omaha N.A.S.E. National Ben Franklin Insurance National Casualty National Continental Insurance National Fire Insurance Company of Hartford National Health Insurance National Indemnity National Union Fire Insurance of LA National Union Fire Insurance of PA Nationwide General Insurance Nationwide Mutual Fire Insurance Nationwide Mutual Insurance Nationwide Property and Casualty New York Life Insurance Northwestern Mutual Life Northwestern Pacific Indemnity Omni Indemnity Omni Insurance Orion Insurance Pacific Indemnity Pacific Insurance Pafco General Insurance Patriot General Insurance Peak Property and Casualty Insurance PEMCO Insurance Progressive Progressive Auto Pro Prudential Insurance Co. Reliance Insurance Reliance National Indemnity Reliance National Insurance Republic Indemnity Response Insurance SAFECO Safeway Insurance Safeway Insurance Co of AL Safeway Insurance Co of GA Safeway Insurance Co of LA Security Insurance Co of Hartford Security National Insurance Co of FL Sentinel Insurance Sentry Insurance a Mutual Company Sentry Insurance Group Shelter Insurance Co. St. Paul St. Paul Fire and Marine St. Paul Insurance Standard Fire Insurance Company State and County Mutual Fire Insurance State Farm County State Farm Fire and Cas State Farm General State Farm Indemnity State Farm Insurance Co. State Farm Lloyds Tx State Farm Mutual Auto State National Insurance Superior American Insurance Superior Guaranty Insurance Superior Insurance The Ahbe Group TICO Insurance TIG Countrywide Insurance Travelers Indemnity Travelers Insurance Company Tri-State Consumer Insurance Twin City Fire Insurance UniCare United Pacific Insurance United Security United Services Automobile Association Unitrin Direct USAA Casualty Insurance USAA General Indemnity USF and G Viking County Mutual Insurance Viking Insurance Co of WI Windsor Insurance Woodlands Financial Group What date does your current policy expire/renew?

Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Year 2007 2006 2005

How long have you been insured with your current insurance company? # of Years: 0 1 2 3 4 5 6 7 8 9 10+ # of Months: 0 1 2 3 4 5 6 7 8 9 10 11 How long have you had this property continuously insured? # of Years: 0 1 2 3 4 5 6 7 8 9 10+ # of Months: 0 1 2 3 4 5 6 7 8 9 10 11

END OF YES CODE

SECTION 4

Note: Based on your answers so far, you will be quoted for a dwelling policy. Standard levels of other coverages not listed will be included in the policy quotes based on your state and answers to the questions below.

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How much Residence coverage do you want?   (In dollars; for example: 250,000)
How much personal liability coverage do you want?	100,000 300,000 500,000 1,000,000
Are you interested in an umbrella type of policy?
How much deductible? (The higher your deductible, the lower your premiums)	100 250 500 1000 2000
Approximate year property built:
Approximate livable square footage of residence: (Excluding basement, if any)
Is this your primary or secondary residence?	Primary Secondary
Have you reported any claims or losses to your insurance company within the past 5 years?	YesNo
Is business or farming conducted on this property?	YesNo
Do you have any of the following breedsof dogs: Chow, Doberman, German Shepherd, Pit Bull, Rottweiler, Wolf Hybrid, or mix of these?	YesNo

Dwelling design:	--Select-- One Story Bi Level Two Story Tri Level Other	Exterior wall type (60% or more):	--Select-- Aluminum Or Vinyl Siding Mostly Brick Mostly Wood Frame Stucco Cinder Block Mostly Stone Veneer Log Other
Number of bedrooms:	--Select-- 1 2 3 4 5 6 7+	Number of bathrooms:	--Select-- 1 1.5 2 2.5 3 3.5 4+

In some cases we have pre-selected the most common answers to the questions below. Please adjust as necessary.

Roof type:	--Select-- Composition Shingle Tile Wood Shingle Concrete Other	Roof age:	--Select-- 1-5 years 6-10 years 11+ years
Garage type:	--Select-- Attached - 1 Car Attached - 2 Car Attached - 3 Car Attached Carport Detached - 1 Car Detached - 2 Car Detached - 3 Car Detached Carport No Garage Other	Describe Foundation or Basement:	--Select-- Bsmt Fully Finished Bsmt 3/4 Finished Bsmt 1/2 Finished Bsmt 1/4 Finished Bsmt Unfinished Crawl Space Piers Pilings Stilts Slab Other
Wiring type:	Unknown Copper Aluminum Knob And Tube	Service panel type:	Fuse Box Circuit Breaker Unknown Other
Burglar Alarm:	None Monitored Unmonitored Unsure	Central Fire Alarm:	None Monitored Unmonitored Unsure

Fire station:

Within 5 Miles Within 10 Miles Over 10 Miles

Fire hydrant:

Within 1000 Feet Over 1000 Feet

Municipal location:	Inside City Limits Outside City Limits
Please describe the heating system in this dwelling:	--Select-- Gas (Forced Air) Electric Boiler Oil/Coal/Kerosene Propane Stove Unknown Other
Number of gas, pellet or wood fireplaces or stoves:	--Select-- 0 1 2 3 4 5
Is your home prone to flooding or located in a designated flood plain?	--Select-- Not Applicable Designated Flood Plain Prone To Flooding

Property Accessories (Check all that apply)

Dead Bolts Air Conditioning Swimming Pool Smoke Detectors Covered Deck/Patio Tennis Court Fire Extinguisher Uncovered Deck/Patio Trampoline Indoor Fire Sprinkler

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Owner's First Name: Owner's Last Name:

Owner's Date of Birth:

Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Year 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900

Owner's Gender: MaleFemale

Owner's Social Security Number :
(OPTIONAL BUT HELPFUL)

Co-Owner's First Name :		Co-Owner's Last Name:
Co-Owner's Date of Birth:	Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900	Co-Owner's Gender:	MaleFemale
Co-Owner's Social Security Number : (OPTIONAL BUT HELPFUL)

How would you (owner) describe your credit rating?

Poor  Good  Excellent  Unsure

PLEASE READ: Many consumers who shop for homeowners insurance are also interested in mortgage protection insurance.  Mortgage protection insurance pays the outstanding balance on your home loan should an owner pass away. To receive quotes from additional agents for mortgage protection insurance, select “yes.”

Yes No

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