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SKORUSA.com Home Owners-Insurance Quote Form
Personal Information
All information is treated with strict confidence.
Your FIRST Name:*
Your LAST Name:*
Your DOB*
 
Marital Status*
Property Address to be insured:*
Mailing address (if different from Property To Be Insured)
City:*
State:*
Zip Code:*
County:*
Best Phone Number to reach you:*
E-Mail Address:*
Highest Education Level
Are you a member of AAA?*
AAA ID# (If applicable)
Name of Spouse or Co-Owner:
Spouse or Co-Owner D.O.B.
 
If you have moved in the past 3 years, what was your previous address?
How many years have you lived at current address?
Is home in a trust? (If Yes, indicate if Irrevocable or Revocable and Name of Trust)*
Current Carrier Information
Who is your CURRENT home owner insurance company?
Insurance Carrier Name:
# of years with current Carrier?*
When does your CURRENT home owner policy renew?
Next Renewal Date:*
Effective Date of New Coverage?*
Approximate Current Annual Premium*
Tell Us About Your Home
Type of Home*
Year Built*
Exterior Walls are made of what? Must = 100% (Ex. 80% veneer brick 20% vinyl siding)*
Furnace Yr Updated*
Plumbing Yr Updated*
Electrical Yr Updated*
Roof Yr Updated*
Square Footage*
Electric*
# of Amps?
Year Home Purchased*
Is the dwelling considered an earth home, geodesic home, dome home, berth home, yurt, or have an open foundation? IE. Pier, stills*
No
Yes
# of Stories*
Foundation*
% of Foundation Type (Must = 100%) Ex. 25% Crawlspace 75% Baement*
Garage*
How many FULL Bathrooms*
How many HALF Bathrooms*
Roof Type*
Add-Ons? (Select all that Apply)*
Deck? If YES # of Sq Feet*
Porch? If YES Indicate if Open/Enclosed/Screened & # of Sq Feet*
Fireplace?*
Yes
No
Swimming Pool*
Yes No 
If Yes, Is it Above Ground or Inground?
Diving Board*
Yes No No Pool 
Trampoline*
Yes No 
Deductible*
Dwelling Coverage Amount*
Liability Protection Limit*
Medical Coverage*
Sump/Water Back-Up Limit*
Monitored Burglar Alarm?*
Fire Extinguisher(s)*
Dead Bolt Locks?*
Do you own a DOG?*
Yes No 
Type of Dog(s)
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:
Example: 1 ct yellow gold necklace appraised 2006 for $5000
Current Mortgage Co Name, Address, Loan#*
Insurance premium escrowed?*
Any business conducted in home? (If Yes, what kind of business?)*
Any Home Owner Claims?
Any Home Claims the past 5 Years?*
Yes No 
If Yes, provide details (Date/Type Of Loss/Amount Paid)
Cancelled or NonRenewed in last 5 yrs?*
If Yes, provide reason
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 
Do you want an Umbrella quoted? If Yes, how much coverage?
Term Life Insurance quote
Yes No 
Do you want a quote on Flood Insurance?
Yes No 
How did you hear about us?*
Please provide any additional comments or questions here:
NO COVERAGE OF ANY KIND IS BOUND OR IMPLIED BY SUBMITTING INFORMATION VIA THIS ONLINE FORM
* By submitting this information, you agree that we may use information from you and other sources, such as driving, claims, and insurance score histories, to calculate an accurate price for your insurance.
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