Homeowners Insurance Quote Form

Name 
Address of Property
Desired effective date of policy (mm/dd/yyyy)
Is this for a home you are currently living in?
If so, who do you currently have home insurance with, and how long have you been insured with that company?
What year was the home built?
What month and year did you purchase the home? (mm/yyyy)
Please choose a home type
If the policy will be for a new home purchase, what is the closing date?
Is the home one or two story?
If so is it a 1 car, 2 car, or 3 garage?
Do you have a garage?
Is the garage and attached or unattached garage?
How old is the current roof? 
What type of siding does the home have?
Does the home have a basement? 
If so, is the basement partially or fully finished?
If no basement, is the home on a slab or crawlspace foundation?
How many fireplaces? 
Type of fireplaces (if any)
How many of the rooms have vaulted or cathedral ceilings? 
How many of the rooms have crown molding? 
How many baths does the home have? (how many full baths and how many half-baths) 
Is the home mainly carpeted?
If not, what kind of flooring does the home have?
What are the kitchen counter tops made of? (Formica, Wood, Granite, etc.)
How is the home heated? (Gas or Electric)
Does the home have central air conditioning?
Have any of the following been renovated since the home was built? (choose one or more)
Please provide approximate date of renovation for all selected above
How many people live in the home?
How many are over the age of 18?
How many smokers live in the home?
Are you within 5 miles of a fire station?
Are you within 1,000 feet of a fire hydrant?
Do you own any dogs?
If so, what breed, and how many?
Do you have a swimming pool or trampoline on the premises?
Do you have smoke detector on each floor?
Do you have fire extinguishers in the home?
Do you have a burglar alarm?
If so, is it directly connected to a monitoring system?
Do you have a fire alarm?
If so, is it directly connected to a monitoring system?
How many losses/claims have you had in the last five years? (Please provide dates and amounts, if applicable.)
If you would like to add another person to the policy, please provide name and date of birth