NEXUS HOME QUOTE

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NEXUS HOME QUOTE

Personal Information

All information is treated with strict confidence.

Your FIRST Name:*

Your LAST Name:*

Your Date Of Birth*

mm/dd/yyyy

Marital Status*

Property Address to be insured:*

No P O Box

City:*

State:*

Zip Code:*

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

If you have moved in the past 3 years, what was your previous 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

Wind Mitigation Inspection?*

Four Points Inspection?*

Elevation Certificate?*

Tell Us About Your Home

Type of Home*

Year Built*

Square Footage*

Year Home Purchased*

1 or 2 Story Home*

Basement*

Garage*

How many FULL Bathrooms*

How many HALF Bathrooms*

Roof Type

Home Structure Type*

Swimming Pool

Yes No

Diving Board

Yes No No Pool

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

Any Scheduled Personal Property?

None 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

Life Insurance quote

Yes No

Please provide any additional comments or questions here:

Referral Person (If Any)

AGENT NAME (If Known):

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