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If you are interested in a quote for Home Insurance, please fill in the information below, and one of our brokers will be in contact with you shortly.
Name E-mail Phone Number Legal Address
Have you ever had Home Insurance before?
If you have had insurance before, please indicate the date since you have had continuous coverage.
If you currently have Home Insurance, have you had any claims or losses in the last 5 years?
In the last 5 years, have you been refused, or declined property insurance before?
Will the home be owner occupied only, or will there be any renters?
No, just me (us).
Yes, there will be a renter(s) in the home.
What type of home do you own / are you buying?
Single Family Dwelling
Side by Side Duplex
Up/Down Duplex
What type of heat is in your home?
Forced Air Electric
Forced Air Gas
Electric Baseboard
Not Sure
What is the age of the Furnace / Baseboard Heaters?
Less than 10 Years
Less than 20 Years
Over 20 Years
Not Sure.
Is there any wood heat?
How many amps is the electrical panel? (This can be found on the main breaker of the panel, and is "etched" into the tip of the switch.)
60 Amp
70 Amp
100 Amp
200 Amp
Not Sure
Please Indicate if your home has any of the following types of Plumbing. (Check all that apply)
Copper (Usually used as a water supply line, and sometimes as a drain)
ABS (This is the black plastic drain lines)
Pex (This is the plastic water supply lines)
Cast (Usually found in older homes and is part of the drain lines)
I have no idea.
How old are the shingles?
0 - 5 Years
5 - 10 Years
10 - 15 Years
15 - 20 Years
20 + Years
I'm not sure.
What is the current limit of insurance on your home? (If you're buying a new home, just put "Not Sure". What Limit of Sewer Back Up coverage would you like? (Sewer Back Up covers you for any damage caused by water or sewage entering your home through a sump pit, floor drain, or plumbing fixture)
Indicate your age so we know if you qualify for a mature discount.
Under 45
Between 45 - 50
Between 50 - 60
Over 60
Is there a mortgage on the home? (There is a Mortgage Free Discount if there isn't)
What year was your home built? Submit