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Home Insurance Quote Form

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Your Information

Your Name:

Street Address:

Street Address (#2):

City:	State:  OH PA WV Zip:
Phone:	Cell:
Email Address:
Membership Number:
What is your date of birth?	mm/dd/yyyy

In the event that we need to contact you, please provide the following information:

Day:  Monday Tuesday Wednesday Thursday Friday Saturday Time: 

How should we contact you?
Email Phone

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Secondary PolicyHolder/Spouse
Name of other owner or spouse information (if applicable):

Name:

What is his or her date of birth?
 mm/dd/yyyy
Relationship of Secondary Policy Holder Spouse
Co-Owner
Other

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Historical Information
Have you or any members of your household had any homeowners claims or losses in the past 3 years?
Yes No

If yes, please list losses below with the most recent loss first.
Year of loss:

Description of loss:
Select Fire Ice Damage Smoke/Soot Theft/Burglary Tornado Vandalism Water backup from sewers/drains Water All Other Wind/Hail/Lightning Liability Medical Payments Only Liability All Other
Amount paid:

Year of loss:

Description of loss:
Select Fire Ice Damage Smoke/Soot Theft/Burglary Tornado Vandalism Water backup from sewers/drains Water All Other Wind/Hail/Lightning Liability Medical Payments Only Liability All Other
Amount paid:

Year of loss:

Description of loss:
Select Fire Ice Damage Smoke/Soot Theft/Burglary Tornado Vandalism Water backup from sewers/drains Water All Other Wind/Hail/Lightning Liability Medical Payments Only Liability All Other
Amount paid:

Apply Multiple Product Discount? 
Yes No
If Yes, Check all that may apply:
Life Insurance Policy   Car Insurance Policy

Name of your credit union or bank:
(You may be eligible for a special group discount)


Name of any professional organizations you belong to:
(You may be eligible for a special group discount)


Name of your employer:
(You may be eligible for a special Group discount)


What county is the home located in?

Primary Construction of Dwelling:
Brick Frame Aluminum Siding
Year that your home was built:

Does your home have any of the following features?(check as appropriate):

Smoke detector on each level?
Yes No
Audible alarm?
Yes No
At least one fire extinguisher?
Yes No
Centrally monitored security system?
Yes No
Deadbolt locks on all exterior doors?
Yes No

Fire sprinkler system?
NoneSome roomsAll rooms
What is the approximate market value of your home? $

What is the outstanding mortgage amount of your home? $

Please specify the following:
Number of Stories:  
Select1 story1 1/2 stories2 stories2 1/2 stories3 stories4 or more storiesBi-levelTri-level
Total living area in square feet:  

Number of families in household if more than one:  

Basement?
No Yes,
If finished, basement square feet:  

Central Air?
No Yes,
Fireplace(s)?
No Yes,
State number of fireplaces:  

Is garage attached?
No Yes
Size of garage:  
Select1 car2 car3 car4 or more
Attached carport?
No Yes,
Size of carport:  
Select1 car2 car3 car4 or more
Porch?
No Yes,
If Yes,
Open Closed,
 Balcony/Deck?
No Yes,
If Yes, Number of square feet:  

Number of Full Baths:  


Please indicate the year in which any of the following have been upgraded by a licensed professional contractor:
Roof Upgrade - Entire roof replaced or recovered in accordance with state and local codes. 
(yyyy)
Electrical System Upgrade - Installed circuit breaker service of at least 100 amp. 
(yyyy)
Plumbing System Upgrade - Replaced all lead and galvanized water pipes with copper or PVC, and replaced the water heater. 
(yyyy)
Heating System Upgrade - Replaced the furnace. 
(yyyy)

How far is your home from the nearest fire station?  
 miles
Is your home within 1,000 feet of a fire hydrant?
Yes No
If currently insured, amount of coverage on your house (If renters coverage, contents amount): $

Present homeowners insurance company: 

Expiration of present homeowners insurance:
(mm/dd/yy)
Current premium: $

Type of policy:
SelectTraditional (H-3)Renters (H-4)Preferred (H-5)Condominium (H-6)
Deductible:
Select$1,000$500$250$100$50$250 with $500 Theft$100 with $500 Theft$100 with $250 Theft$50 with $250 Theft
Do you have any specially covered items? If yes, please describe items and coverage amounts below: (Jewelry, etc.)

Comments:

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