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Homeowners Insurance
Quotation Form
One Simple Form - takes only 2-3 Minutes!

Your Personal Data:
Your Name:
Property Address:
Your "County" is?
State: (Must be Pennsylvania)
E-Mail again for accuracy:
Fax (optional):
Dwelling Information
Year Home Built:
Home Square footage:
Is this Builder's Risk?
(new home constr.)
Month/Year home
to be complete:
Number of units: 1 family Duplex
Type foundation: Slab
Crawlspace over slab
Pier & Post
Other (list in remarks)
Type Construction: Frame
Other (list in remarks)
Type Roof: Shingle
Wood Shake
Spanish Tile
Metal Other
Number of stories: One 1.5
Two Three
Do you own animals or pets? Yes No
If yes, list type/for dogs, list breed:
Are You Near Brush Area? Yes No
# of feet to nearest
fire hydrant:
# of miles to nearest
fire station:
Does Home Have a Garage? Yes No
Tell whether built in, detached/attached, and how many cars?
Currently Insured? Yes No
Name of Carrier & how long insured?
Prior Claims? Yes No
Describe claims in detail:
Rate Your Credit History and Past Insurance Payment History:
(Some companies products are
based on your credit and payment history.)
Excellent Fair
Poor Horrible
Primary Policyholder's Birthdate:
(Some companies products
offer discounts for certain age groups.)
Plumbing type: Copper Galvanized
Mixed (Copper/Galvanized)
Heating Type: Gas (Propane or natural)
Oil (if oil, list tank location in remarks)
Circuit Breakers or fuses? Breakers Fuses

# Bedrooms: # Bathrooms:
# Fireplaces: # Chimneys:
Special features
(i.e., deck, air conditioning, alarm systems, pool, etc.)
Dwelling Cov. $ Contents $
Liability Cov. $ Deductible $
($250, $500, $1,000, etc.)
(describe any scheduled jewelry, in-home business, oil tank location, or other special coverages/remarks here):
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