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Homeowners Insurance Quote Questionnaire

Splits into two parts: first the personal details of the applicant and spouse, then the specifics of the property to be covered. In one pass an agent learns about the foundation, roof, garage and mortgage, and can receive the current policy pages for review.

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Page 1

Name*

Nombre

Apellido

Date of birth*

Who referred you to us?

Spouse's name (leave blank if not applicable)

Nombre

Apellido

Spouse's date of birth

Current address*

Dirección

Ciudad

Estado / Provincia

Código postal

Address of the home to be insured*

Dirección

Ciudad

Estado / Provincia

Código postal

E-mail*

Home number

Mobile number

Page 2

Home type*

Single-family house Townhouse Condominium Manufactured home Duplex

Foundation type*

Concrete slab Crawl space Basement Pier and beam

How large is the home in square feet?

What year was the roof last replaced?

How many bathrooms are there?*

Does the home have central air conditioning?*

Yes No

Is there a fireplace? If so, is it wood burning or gas?*

Exterior wall type (select all that apply)*

Brick Vinyl siding Wood Stucco Stone Fibre cement

Is there a garage?*

Attached garage Detached garage Carport No garage

Do you have a mortgage on the home?*

Yes No It is fully paid off

Would you like a quote on anything else? Bundling home and auto can lower your premium.

Auto insurance Life insurance Umbrella policy Renters insurance Boat or RV No, thank you

Anything else the agent should know about the home?

You may upload the pages of your current homeowners policy so coverages can be reviewed

Max 10 MB per file

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