Homeowners Insurance Quotation Form One Simple Form - takes only 2-3 Minutes! Your Personal Data:   Your Name: Property Address: City: Your "County" is? State: (Must be Pennsylvania) Zip/Postal: E-Mail (REQUIRED): E-Mail again for accuracy: Phone: Fax (optional):   Primary Policyholder's Birthdate: (REQUIRED - Some companies products offer discounts for certain age groups.)     Dwelling Information   Year Home Built: Home Square footage:   Is this Builder's Risk? (new home constr.) NO YES   Month/Year home to be complete:   Number of units: 1 family Duplex   Type foundation: Basement Slab Crawlspace over slab Other (list in remarks) (If basement, what % is finished?) % FINISHED   Type Construction: Frame Brick/Veneer Stone Other (list in remarks)   Type Roof: Shingle Wood Shake Tar/Gravel 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   Plumbing type: Copper Galvanized Mixed (Copper/Galvanized)     Heating Type: Gas (Propane or natural) Electric 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.)   Coverages:   Dwelling Cov. $ Contents $ Liability Cov. $ Deductible $ ($250, $500, $1,000, etc.)   Comments/Remarks (describe any scheduled jewelry, in-home business, oil tank location, or other special coverages/remarks here):   Send my quotation via: E-Mail Fax Regular Mail Call Me By Phone Thank you for filling out this form COMPLETELY! We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy. Yes, I Agree. Please Send Me a Quote NOW! Click Button Below When Done Please Click Only Once . . . May take up to 30 seconds!	Pennsylvania Personal and Commercial Auto Insurance Discounts! Let us shop your Pennsylvania Auto Insurance for you. Ask about our 8% PAID-IN-FULL Auto Insurance Discount! Great values on: • Good Drivers • Multi Car Accounts • Home & Auto Combo • Fleet Discounts Get a FAST Personal Auto Quote Get a FAST Business Auto Quote   Hi Value Homes and $$ Multi-Million Estate Packages! We have the perfect homeowners solution for your high valued home. Low rates and maximium discounts. Get a Quote Condo and Renters Insurance Programs for Pennsylvania Now Available! If you are in need of Condo Insurance, or Renters Insurance, we can place coverage FAST and inexpensively. We also specialize in Personal Umbrella Coverage! Protect the Assets You Have Worked For! Get an Umbrella Quote   Business Owner's Program We specialize in business policies for most Pennsylvania retail, wholesale, and offices. We shop several carriers for the broadest coverage at the lowest price! CLICK FOR QUOTE NOW!
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