Information About Your Home Address of Property to be Insured, (only if different from above)  State: Rhode Island Connecticut Alabama Alaska Arizona Arkansas California Colorado Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Is this your primary residence?   Yes   No Number of Families in Residence:   Year Built Construction Wood/Frame Brick/Masonry Repair Dates Roof Installed   (year) Wiring Updated   (year) Plumbing Updated   (year) Heating Updated   (year) Please check if you have: Central Heat Wood or Coal Stove Trampoline Swimming Pool             If you have a swimming pool, is it fenced in and locked?            Yes No             Does it have a diving board?             Yes No A Dog    Of What Breed(s) Additional Information About Your Home Name of Responding Fire Department Approx. Distance to Fire Dept (in miles) Approx. Distance to Hydrant (in feet) Do You Have Any of the Following? Smoke Detectors Fire Extinguisher Dead Bolt Locks on All Exterior Doors Burglar/Fire Alarm Is any business or child care conducted on your property? Yes No    What Type? In Coastal States only: Distance to Water (miles) Additional Coverage Options Please check which of the following items you'd like coverage for and enter the corresponding dollar value of the item(s): Item Value   Item Value Jewelry   Musical Instruments Furs   Firearms Fine Arts   Other Please visit our link to Flood Insurance once you've submitted this form, to learn more about flood insurance. Would you like a Flood Insurance quote?  Yes  No Please visit our link to Umbrella Coverage once you've submitted this form, to learn more about Umbrella coverage. Would you like an Umbrella policy quote?  Yes  No How much coverage would you like a quote for?  $1,000,000  $2,000,000 Information About Losses, etc. Have you had any property insurance claims in the last 5 years? Yes No     If Yes, Describe, Including Date and Amount paid.     Has any company declined, cancelled or refused to renew similiar coverage for you in past 5 years? Yes No     If Yes, Give Dates / Details Below.     Have you or a household member had a foreclosure, repossession, bankruptcy, or lien in the past 5 years? Yes No Information About the Value Of Your Home Please fill in the following only if you own a house: What your home would sell for today $ Home currently insured for $ The square feet of living space is: Statement Of Understanding You understand that there is no coverage in force until an application is approved and premium is received by our agency. A representative will contact you about the premium amount and payment method. You certify that the statements made on this quote request are accurate to the best of your knowledge. You agree that a quote request shall constitute a part of any policy issued whether attached or not. Fraud Warning Any person who, with the intent to defraud or deceive, submits information or files a statement of claim containing any false, incomplete or misleading information, or helps in any manner to commit a fraud against an insurer, may be subject to civil penalties and criminal prosecution for insurance fraud. *Some of our companies use financial responsibility (or credit scoring) in order to provide you with the best quote. If you would like to discuss this option further, please don't hesitate to call us. If you are not comfortable providing us with your social security number over the internet, please call us for a quote at 348 - 2000.