Homeowners Insurance Quote (Long Form)

Quote Request

Please complete the Homeowners Insurance Long Form, if you have specific details to list regarding your home and insurance needs.

    Personal Information

    *First Name

    *Last Name

    Mailing Address

    City/St/Zip

    *Phone Number

    Alternate Number

    Birth Date

    *Email Address

    Property Information

    Property Street Address


    Dwelling Type

    Number of Bedrooms

    Number of Bathrooms

    Number of Fireplaces

    How many porches or decks are there?

    What year was it built?

    What date was the property purchased?

    What is the construction type?

    How many stories is it?

    If two stories, what is the ground floor square footage?

    Total square footage

    What is the property's topography?

    What foundation type?

    If structure is located in a flood zone, what is the distance to body of water?

    Garage Description

    What type of roof covering?

    Was the roof updated?

    YesNo

     

    If yes, what year?

    Does the building have a pool?

    YesNo

     

    If yes, is it fenced? YesNo

    If there is a pool, is there a diving board?

    YesNo

     

    If there is a pool, is there a slide? YesNo

    What is the distance to fire protection?

    Is the building in the brush?

    YesNo

    Is there a brush hazard within one mile of the building?

    YesNo

     

    If yes, has the brush been cleared by 250 feet from all sides of the building? YesNo

    Is there a smoke alarm installed?

    YesNo

    Is there a fire extinguisher?

    YesNo

    Are there deadbolts?

    YesNo

    Is the electrical updated?

    YesNo

    Are there circuit breakers?

    YesNo

    Does the electrical circuit box have copper wiring?

    YesNo

    How old is the heating/ air conditioning?

    Is the heating / air conditioning thermostatically controlled?

    YesNo

    What is the energy source?

    What is the heating system?

    What is the cooling system?

    Has the plumbing been updated?

    YesNo

    Is the plumbing copper?

    YesNo

    Does the building have interior automatic fire sprinklers?

    YesNo

    Is there a theft alarm?

    YesNo

    What is the earthquake zone?

    Has it been earthquake retroffited?

    What is the fire district?

    Are there dogs on the property?

    YesNo

     

    If yes, how many and what is the breed of each dog?

    Are there any other pets or animals on the property?

    YesNo

     

    If yes, how many and what is the description of each?

    Current Coverage Information

    Current Insurance Company

    Expiration Date

    Were there any losses or claims in the last 5 years?

    YesNo

     

    If yes, what is the date, amount paid and description of each loss or claim?

    Desired Coverage Information

    Dwelling Amount - Coverage A

    Other Structures - Coverage B

    Personal Property - Coverage C

    Loss of Use - Coverage D

    Premise Liability - Coverage E

    Policy Deductible

    If earthquake insurance is requested, select deductible percentage %

    Do you want building replacement cost coverage?

    YesNo

    Do you want contents replacement cost coverage?

    YesNo

    Questions or Comments

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