Homeowners Insurance Quote Request
Full Name of Property Owner:
Address:
Address (cont.):
City:
State:
Zip:
Home Phone:
Cell Phone:
Email:
What year did you purchase/build the home?:
What year was the home built?:
Total living area? (sq. ft.):
Number of stories:
Select
1
1.5
2
2.5
3
Number of families who live in the home?:
Select
1
2
3
4
Exterior wall construction:
Select
Concrete Block w/ Stucco
Concrete Block - Painted
Concrete Block w/ Vinyl/Aluminum Siding
Poured Concrete
Frame w/ Stucco
Frame w/ Hardie Board Siding
Frame w/ Wood Siding
Frame w/ Vinyl/Aluminum Siding
Solid Brick
Other
Unknown (not sure)
Type of roofing material?:
Select
Basic 3-tab Asphalt Shingles
Arch/Dim 5-tab Asphalt Shingles
Metal
Clay/Ceramic Tile
Slate
Wood shingles
Built Up/Tar & Gravel
Other
Unknown (not sure)
Type of roof design?:
Select
Hip Roof
Gable
Flat
Other
Unknown (not sure)
Year roof was installed/replaced:
Year Heating & Air Conditioning system was installed/replaced:
Year electrical wiring system was installed/upgraded:
Year plumbing system was installed/upgraded:
Type of Heating System?:
Select
Electric
Gas
Unknown(not sure)
Year hot water heater was installed/replaced:
How would you describe the quality of your kitchen?:
Select
Basic
Standard
Custom
Designer
Number of Bedrooms:
Select
1
2
3
4
5 or more
Number of Full-Bathrooms:
Select
1
2
3
4
5 or more
Number of Half-Bathrooms:
Select
None
1
2
3
4
5 or more
Number of 3/4 Bathrooms:
Select
None
1
2
3
4
5 or more
How would you describe the quality of your bathroom(s)?:
Select
Basic
Standard
Custom
Designer
Fireplace:
Select
None
Fireplace - Single
Fireplace - Double
Fireplace - Triple
Free Standing "Wood Stove"
Pre-Fab - Zero Clearance
Garage:
Select
None
Attached - 1 Car
Attached - 2 Car
Attached - 3 Car
Built-In - 1 Car
Built-In - 2 Car
Built-In - 3 Car
Open Porch:
Select
None
Small - Approx. 100 Sq. Ft.
Medium - Approx. 150 Sq. Ft.
Large - Approx. 240 Sq. Ft.
Screened Porch:
Select
None
Small - Approx. 100 Sq. Ft.
Medium - Approx. 150 Sq. Ft.
Large - Approx. 240 Sq. Ft.
Swimming Pool:
Select
None
Small - Approx. 450 Sq. Ft.
Medium - Approx. 650 Sq. Ft
Large - Approx. 900 Sq. Ft.
Pool Enclosure:
Not Applicable
No
Yes
Balcony:
Select
None
Small - Approx. 150 Sq. Ft.
Medium - Approx. 350 Sq. Ft.
Large - Approx. 650 Sq. Ft.
Breezeway:
Select
None
Open - Approx. 150 Sq. Ft.
Open - Approx. 350 Sq. Ft.
Open - Approx. 650 Sq. Ft.
Screened - Approx. 150 Sq. Ft.
Screened - Approx. 350 Sq. Ft.
Screened - Approx. 650 Sq. Ft.
Closed - Approx. 150 Sq. Ft.
Closed - Approx. 350 Sq. Ft.
Closed - Approx. 650 Sq. Ft.
Patio Cover:
Select
None
Small - Approx. 100 Sq. Ft.
Medium - Approx. 150 Sq. Ft.
Large - Approx. 240 Sq. Ft.
Wood Decking:
Select
None
Small - Approx. 100 Sq. Ft.
Medium - Approx. 150 Sq. Ft.
Large - Approx. 240 Sq. Ft.
Intercom System:
No
Yes
Central Vacuuming System:
No
Yes
Solar Panels:
No
Yes
Do you have a trampoline?:
No
Yes
Do you have a dog?:
No
Yes
Do you have a monitored security system?:
No
Yes
Do you have monitored fire alarm system?:
No
Yes
Do you have professionally installed hurricane shutters?:
No
Yes
Has a qualified inspector completed a windstorm mitigation inspection on your home?:
No
Yes
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