Homeowners Insurance Quote

HOMEOWNERS INSURANCE QUOTE

Applicant / Insured Information

Applicant Name:

Date of Birth:    Primary Phone:

Property Information

Year Built:    Square Footage:

Construction Type:  Wood  Masonry  Mixed

Occupancy: Primary Residence  Secondary/Seasonal  Rented to Others

Policy Details & Coverage Limits

Policy Form:  HO-3 (Special Form)  HO-5 (Comprehensive)

Deductible Options:  $500  $1,000  $2,500  Other:

Policy Period Start:    End:    Quote Issue Date:

Coverage Options & Endorsements

Flood Insurance (not included unless selected)   Earthquake Coverage

Identity Theft Expense   Water Backup/Sewer Overflow

Scheduled Personal Property (jewelry, fine arts) — Provide item list below if selected

Exclusions (Representative)

The following are common policy exclusions and are included here for disclosure. This quote does not provide coverage for: flood damage (unless separate flood insurance is purchased), earthquake (unless endorsed), wear and tear, gradual deterioration, mold not caused by a covered peril, damage resulting from deliberate acts by the insured, nuclear hazard, war and insurrection, and losses otherwise excluded by express policy terms. Additional exclusions may apply and will be set forth in the issued policy.

Claims History

Any claims or losses in the past five (5) years?  Yes  No

Date of Loss:    Estimated Amount Paid:

Beneficiary / Payee for Policy Proceeds

Primary Payee Name:

Relationship to Insured:    Percentage Share:

Underwriting / Additional Information

Home Security System  Monitored Smoke/CO Detectors  Claims-Free Discount

Declaration and Certification

I certify that the information provided in this application for quotation is true and complete to the best of my knowledge. I understand that this document is a quotation and summary of proposed coverages only and does not constitute an insurance policy. Coverage and premium are subject to underwriting approval, verification of the information provided, satisfactory inspection where required, and receipt of any required premium. Any intentional misrepresentation, concealment or omission of material facts may result in declination of coverage, rescission of the policy, or denial of claim payments.

By signing below I acknowledge receipt of this quote, agree that the answers contained herein are accurate, and authorize the insurer and its representatives to obtain and verify information necessary to underwrite the risk.

Sign Now