Home Quote Form
Full name?
**
Current address?
**
Phone number?
**
Fax number?
Cell phone number?
Is this a new home?
yes
no **
What year was this home built?
**
How many square feet is your home?
**
Is your home a 1 story, 2 story, cape cod, or split?
1 story
2 story
cape cod
split **
Is this house all or mostly sided, frame, or brick?
sided
frame
brick **
Number of bedrooms?
1
2
3
4
5 **
Number of full bathrooms?
1
2
3
4 **
Number of half bathrooms?
1
2
3 **
Eat-In Kitchen?
yes
no **
Dining room?
yes
no **
Family Room?
yes
no **
Basement?
No
Yes, unfinished
Yes, finished **
Central Air?
yes
no **
Fireplace? If yes, what type?
**
garage?
no
yes, single
yes, double
yes, triple **
Is the garage attached?
Attached
Detached
Built-in
I don't have a garage **
Pool?
no
yes, above ground
yes, below ground
Deck size (sq. ft.)?
Dogs? (# of)
Breed?
Dead bolts?
yes
no **
Smoke Alarms?
yes
no **
Fire Extinguisher?
yes
no **
Purchase Price?
**
Year purchased?
**
Current insurer?
For how many years?
Credit Rating?
excellent
average
below average
poor **
Deductible?
250
500
1000 **
Replacement coverage?
prior losses?
**
If so, when?
**
Current auto carrier?
Water Back-Up coverage?
yes
no **
Satelite? If yes, what is its value?
What is your E-Mail address?
