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Homeowner's Quote

Personal Homeowners Quote

Date:
Name:
Owner:
Property Address:
City:
State:
Zip:
Mailing Address:
City:
State:
Zip:
Telephone:
Fax:
Contact Name:
Email Address:
How did youo hear about us?:
If Yellow Pages, did you respond to the:
 HG Logo
Kemper
CIG
Other
Home Facts:
Year Built:
Square Footage:
Dist. Hydrant/Station:
Single Family:
 Yes  No
Roof Type:
Heat Type:
# of Bedrooms:
# of Bathrooms:
# of Stories:
Fireplace:
 Yes  No
Chimney:
 Yes  No
Pre-Fab:
 Yes  No
Garage:
 No  Attached  Detached
Central Air:
 Heat Ducts  Separate  
Deck:
 Yes No sqr. ft.
Foundation:
 Yes  No  Slab
Earthquake Coverage:
Do you want Earthquake coverage?:
 Yes  No
Is you home retrofitted?:
 Yes  No
Is your foundation bolted?:
 Yes  No
Do you have shear walling?:
 Yes  No
Updates (if over 30 years):
Wiring:
 Full  Partial
Plumbing:
Heating:
Roof:
Any losses in last three (3) years?: Yes  No
If Yes, describe:
Currently insured?: Yes  No
If Yes, how much is...  
the dwelling limit:
liability:
deductible:
Current Carrier:
Renewal Date: dd-mm-yyyy
Escrow closing Date: dd-mm-yyyy