Home Owner's Insurance
Fields marked with
*
are required.
Home/Condo/Apartment Quote Form
Section A
Date
August 29th, 2008
Name
* Phone
* Email Address
Address
City
State
Zip
Groups & Associations discount?
None
Partner-School employee
Athens Chamber member
American Legion
OH Cattlemen's
University Estates
Property location
(if different)
Township
County
Validation Code
* Please enter the 5 character verification code:
Only click here if you're NOT filling out Section B below.
Section B
Year built
Number of families
Responding fire dept.
Distance to fire dept.
miles
Distance to hydrant
feet
Property type
primary
seasonal
rental
Primary heat source
electric
gas (tank)
gas (line)
oil
wood
other
Used for business?
Yes
No
Sq. footage
Number of stories
Basement
none
finished
unfinished
partial-finish
Does the unit have any of the following?
wood burning stove
fire extinguisher
fireplace
trampoline
smoke detector(s)
deadbolt locks
pool
air condition
pets (types
)
If older home (25+ yrs) any updates done (indicate year)
wiring
(year
)
plumbing
(year
)
heating
(year
)
roof
(year
)
Coverage needed
dwelling
$
other structures
$
contents
$
loss of use
$
liability
$
medical pay
$
Previous carrier
Policy #
Any losses in the past 3 years?
Leinholder?
Date of birth
/
/
Marital status
Occupation
If married
Spouse's DOB
/
/
Validation Code
* Please enter the 5 character verification code:
