Atkins Insurance Agency
Home Insurance Quote Form |
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Full Name: |
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Phone numbers: |
Daytime: |
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Fax: |
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Email: |
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Address: |
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City /
County: |
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State: |
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Zip code: |
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Inside City Limits?
Yes or No |
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Social security number: (optional) |
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Date of birth: |
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STRUCTURAL INFORMATION |
How many
stories is your home? |
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What is the
total square footage
of the living area of your home? |
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WHAT
IS THE STRUCTURE OF THE FOLLOWING |
Roof: |
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Exterior of
your home: |
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Foundation: |
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Garage: |
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HOW
MANY OF THE FOLLOWING DO YOU HAVE IN YOUR HOME |
Full
bathrooms: |
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Half
bathrooms: |
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Fireplaces: |
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DO
YOU HAVE THE FOLLOWING AT YOUR HOME |
Swimming
pool? |
Yes
No |
Trampoline? |
Yes
No |
Burglar
alarm? |
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Dog? If yes list breed in remarks below. |
Yes
No |
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IS
YOUR HOME LOCATED |
Within 1000
feet from a fire hydrant? |
Yes
No |
Within 5 miles
from the fire station? |
Yes
No |
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GENERAL QUESTIONS |
Year home
built: |
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Heating and
cooling system: |
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Is business
conducted on the premises? |
Yes No |
Did you
experience any loss or claims in the last 5 years? if yes, explain
below. |
Yes No |
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PROTECTIVE
DEVICES |
Smoke
detectors? |
Yes No |
Fire
extinguishers? |
Yes No |
Fire alarm? |
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Deadbolt
locks? |
Yes No |
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HOMEOWNERS
COVERAGE'S AND DEDUCTIBLES |
Dwelling:
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$
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Personal
liability: |
$
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Medical
payments: |
$
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Desired
deductible: |
$
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ADDITIONAL
DATA |
If you have a
collection that is anything of value such as Coins, Stamps, Art etc., specify the value of
your collection: |
$
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If you have
any furs or jewelry, please specify the approximate value/limits: |
$
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For homes 20 years or
older please provide update information regarding wiring, electrical,
plumbing, roofing, heating and cooling in the remarks section. We
will need this information to quote the risk.
REMARKS
We would like to provide you
with a free, no obligation insurance quote. Please provide as
much information possible for the most accurate quote. This
information will be kept confidential and will be used for quote
purposes only. We are committed to protecting your private information.
Atkins Agency does not sell information about you to others.
Online insurance quotes are NOT applications for
insurance. Online insurance quotes are estimates only, based on
the information you provide, and are subject to change based on
verification of information, including identification
of the property or risk to be insured,
claim and credit history, and/or information contained on other consumer
reports. |
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