Home Owners-Insurance Quote Form

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We follow the highest industry standards to safeguard the confidentiality of your personal information and secure the transmission of your information from your computer. Please fill out this form as completely as possible to ensure an accurate quote.

Your FIRST Name:*

Your LAST Name:*

Your DOB*

mm/dd/yyyy

Marital Status*

Property Address to be insured:*

No P O Box

City:*

State:*

Zip Code:*

Occupation:*

Social Security Number: Not required for WA

Best Phone Number to reach you:*

include area code

E-Mail Address:*

Name of Spouse or Co-Owner:

leave blank, if none

Spouse or Co-Owner D.O.B.

mm/dd/yyyy

Current Address*

Current Carrier Information

Who is your CURRENT home owner insurance company?

Insurance Carrier Name:

When does your CURRENT home owner policy renew?

Next Renewal Date:

Approximate Annual Premium

Tell Us About Your Home

Type of Home*

If Renting, Total of Personal Belongings (Example 15K, 25K etc.)

If Condo, Cost of Personal Belongings -Drywall to Drywall

Year Built*

Square Footage*

Year Home Purchased*

Describe your Home:*

What is the siding made of?*

Basement*

Crawl Space*

Garage*

Garage Type*

How many FULL Bathrooms*

How many HALF Bathrooms*

Roof Type*

What year was the roof replaced?*

Home Structure Type*

Heating/AC*

Was the heating updated, replaced, yearly check-up?  When and what year?*

Was the plumbing updated, replaced, yearly check-up?  When and what year?*

Copper or Plastic piping?*

Was the Electricity updated, replaced, yearly check-up?  When and what year?*

Any Aluminum Wiring?*

Yes No

Swimming Pool*

Yes No

Diving Board

Yes No No Pool

What is the Amount of Coverage A*

What is the Amount of Coverage B*

What is the Amount of Coverage C*

What is the Amount of Coverage D*

What is the Amount of Coverage E*

Deductible

Liability Protection Limit

Medical Coverage

Do you own a DOG?*

Yes No

Type of Dog

leave blank, if none

Any Dog BITE CLAIMS the past 5 years?

Yes No Not Applicable

Do you shelter any unusual or exotic animals?*

Yes
No

Do you have any Roomers or Boarders?*

Yes
No

Is there any Business conducted on the premises including Farming or Ranching?

Yes
No

Any Scheduled Personal Property?

None Music Instuments Jewelry Guns Collectibles Other

Describe any Scheduled Personal Property and Coverage Amounts:

leave blank, if none

Example: 1 ct yellow gold necklace appraised 2006 for $5000

Any Home Owner Claims?

Any Home Claims the past 3 Years?

Yes No

Describe any home owner claims

May we help you in any other way?

Give me an AUTO quote

Yes No

Quote my Boat, ATV, RV, Motorcycle, or Trailer

Yes No

Term Life Insurance quote

Yes No

Please provide any additional comments or questions here:

In order to provide you with the most accurate quote possible, All in One Insurance Group will obtain your credit-based insurance score from a consumer reporting agency. If you decide to apply for a policy through an All in One Insurance Group Agent, we may obtain additional reports to verify the driving records of some or all persons to be covered under the policy, along with prior claims history reports of the named insureds, which may include information about other drivers in the household. Most automobile insurers use credit information, in conjunction with other factors, to calculate an insurance premium for new customers. Our use of this information will not have an effect on your credit history.

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