HOME OWNER'S INSURANCE QUOTE

Please fill out as much information as possible. Items marked with a * are required items.

By clicking submit, you agree that no coverage of any kind is bound or implied by submitting this information on our online form
GENERAL INFORMATION
First Name *
Last Name *
Address *
City *
State *
Zip *
Day Phone *
Evening Phone
E-mail Address *
CURRENT INSURANCE INFORMATION (If applicable)
Who is your home insured with now?
When does your policy expire?
How much are you insured for?
What is your premium?
What is your mortgage amount?
Have there been any claims in the last 3 years?
TELL US ABOUT YOUR HOME
What year was your home *
How many stories is your house? *
What is the total square footage of your house? *
How much liability coverage would you like? *
What is the market value of your house? (If unsure simply state "Don't know") *
How long have you lived in this house? *
What is the type of construction of the house? *
What type of roof do you have? *
How many car garage do you have? *
What type of garage do you have? *
How many bedrooms? *
How many bathrooms? *
How many fireplaces? *
Do you have any built on porches or patios? *
ADDITIONAL INFORMATION
How far is the closest Fire Station *
Do you have a basement? * Yes
No
What is the approximate square footage of the basement?
Do you have a swimming pool? * Yes
No
Do you have a security system? * Yes
No
Do you have smoke detectors in your house? * Yes
No
Please list any additional comments or questions you may have
  


Form created for Jeff Klusmann Insurance Agency, Inc. using : Bored.com products
HOME | ABOUT US | CONTACT US | GET A QUOTE | RESOURCE LINKS | PRIVACY STATEMENT
Copyright 2009, 2017 Jeff Klusmann Insurance Agency, Inc.