Copyright 2008
© Holloway Insurance Agency
info@hollowayinsuranceagency.com
Designed & Hosted by:
WWWorldHosting.com
"Home Owners Insurance Quote Form"
Home Owners Insurance Quotation Request
1. Name of Owner: (First & Last)
2. Street Address, City, State and Zip Code:
3. Phone # w/area code:
4. Fax # w/area code:
5. Email address:
6. Best Call Time:
A.M./P.M.
7. Property Street Address, City, State and Zip Code:
8. Age of Property:
9. Roof Type & Age:
10. Nbr of Stories:
11. Is It Tri-Level/Duplex/Tri-Plex/Other:
12. Nbr of Garages/Parking Spaces:
13. Total Sq. Footage of Property (Important):
14. Please Give Specific Answer or Yes/No: Gas:
Electric:
# of Fire Places:
Year Upgraded:
# of Bedrooms:
# of Baths:
# of ½ Baths:
Den:
Living Room:
Kitchen:
Patio/Porch:
Is Property in Fire Area:
Is It Near Water/Ocean:
Distance to Fire Hydrant:
15. Is there an alarm system? (yes/no):
16. Fire Precautions
(fire alarm/smoke detectors)
:
What's the fire district?:
17. Property Value $:
18. Amount of Coverage Requested?:
19. Earthquake Coverage (must inquire):
20. Flood Coverage (must inquire):
21. Cancellations:
22. Reason For Cancellations:
23. Nbr of Losses:
23. Present/Previous Insurance Co.:
24. Policy#:
25. Mortgagee:
26. Address, City, State, & Zip:
27. Loan #:
28. 2nd T.D.:
29. Loan #:
30. Comments:
