Please note: No new coverage is in effect until you receive confirmation of such from our office.x Your Name * Your Mailing Address * City * State * Zip Code * E-mail Address: * Daytime Phone Number * Property Information In what year was your home built? * What is the construction type of your home? * Please select one Frame Masonry Approximate Square Footage: * Number of Stories: * Foundation: * Please select one Basement Crawlspace Slab If basement, percent finished: * Wood, coal or pellet stove in house or any outbuilding? * Yes No Do you have a swimming pool? * Yes No If Yes, is the pool: * Please select one In ground with fence In ground without fence Above ground with fence Above ground without fence Do you have a trampoline? * Yes No If Yes, is the trampoline: * Please select one Netted and in fenced yard No net in fenced yard No net and no fence Central Station Fire/Burglar Alarm System: * Yes No Distance to the nearest fire hydrant? * Please select one Less than 500 ft. Over 500 ft, under 1,000 ft. Over 1,000 ft, under 3 miles Number of acres: * Any land farmed? * Yes No Age of Furnace: * Do you have any pets? * Yes No If yes, list type(s) / breed(s) * If yes, any history of biting or viciousness? * Horses or other livestock? * Yes No If yes, give specifics: * Any insurance claims in last 5 years? * Yes No If yes, give details. Be sure to include the date of loss, type of loss and amount paid. * Current Coverage on House: * Current Personal Liability Limit: * Current Deductible: * Current Premium: * Medical Payments * Please select one $1,000 $5,000 Valuation of Home: * Please select one Actual Cash Value Replacement Cost Unknown Personal Property Valuation: * Please select one Actual Cash Value Replacement Cost Unknown In what County/Township are you located? * Do you have smoke detector(s) installed? * Yes No Home Updates: Enter year updates were made. If year not known, enter "unknown": Roof: * Plumbing: * Wiring: Heating: Optional Property Coverages: * Earthquake Coverage Requested Flood Coverage Requested Sewer/Water Backup Coverage Requested Property Floaters - Indicate limits below: Antiques: * Furs: * Coins: * Jewelry: * Computers: * Stamps: * Fine Arts: * Tools: * Other Floater Coverage: * Limit of Insurance: * Additional Comments Please use the box below to enter any additional information you feel should be considered: Protecting your privacy and identity is very important to us. Your Social Security and drivers license numbers may be required to complete this quote. We will contact you personally for this information.