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SKORUSA.com Home Insurance Quote Form
Personal Information
All information is treated with strict confidence.
Your FIRST Name:*
Your LAST Name:*
Your DOB*
Marital Status*
Marital Status
Married
Single
Divorced
Living w/ Significant Other
Property Address to be insured:*
Mailing address (if different from Property To Be Insured)
City:*
State:*
Choose a State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:*
County:*
How many years have you lived at the above insured property address?*
If you have moved in the past 3 years OR purchasing a new location, what was your previous address?
Is home in a trust? (If Yes, indicate if Irrevocable or Revocable and Name of Trust)*
Best Phone Number to reach you:*
E-Mail Address:*
Highest Education Level
Choose a Highest Education Level
High School
Associates Degree
Bachelor`s Degree
Law or Medical Degree
Name of Spouse or Co-Owner:
Spouse or Co-Owner D.O.B.
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*
Type of Home
Single Family Residence
Ranch
Split Level
Tri-Level
Colonial
Duplex
3 Story Unit Building
Townhouse End Unit
Townhomr Middle Unit
Condo
Manufactured Home
I`m a Renter
Year Built*
Does your home have solar panels? (If Yes, how many?)*
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*
Home Structure Type*
Structure Type
Mostly Frame
Mostly Brick
Metal
Other
Square Footage*
Electric*
Electric Type
Circuit Breakers
Fuses
# 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*
# of Stories
1 Story
1.5 Story
2 Story
2.5 Story
3 Story
3.5 Story
Other
Foundation*
Choose a Foundation
Basement Unfinished
Basement Finished
Crawl Space
Slab
% of Foundation Type (Must = 100%) Ex. 25% Crawlspace 75% Basement*
Garage*
Garage Type
None
1 Car Garage Attached
1 1/2 Car Garage Attached
2 Car Garage Attached
2 1/2 Car Garage Attached
3 Car Garage Attached
4 Car Attached
1 Car Garage Detached
1 1/2 Car Garage Detached
2 Car Garage Detached
2 1/2 Car Garage Detached
3 Car Garage Detached
4 Car Garage Detached1 Car Garage Attached
1 Car Built-In with Rooms Above
1 1/2 Built-In with Rooms Above
2 Car Built-In with Rooms Above
2 1/2 Built-In with Rooms Above
3 Car Built-In with Rooms Above
4 Car Built-In with Rooms Above
1 Car Carport
2 Car Carport
How many FULL Bathrooms*
How many FULL Bathrooms
1
2
3
4
5
How many HALF Bathrooms*
How many HALF Bathrooms
0
1
2
3
4
5
Roof Type*
Roof Type
Asphalt Shingles
Tile/Slate
Wood Shingle
Tar/Gravel
Composition
Other
Add-Ons? (Select all that Apply)*
'25' '99'
Add-Ons? (Select all by Cntrl and Left Click)
None
Central HVAC
Wood Stove
Fireplace x 1
Fireplace x 2
Swimming Pool (Inground)
Swimming Pool (Above Ground)
Hot Tub
Trampoline
Fenced Yard
Business In Home
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*
Deductible
$250
$500
$1000
$2000
Compare $500 vs $1000
Compare $1000 vs $2000
Dwelling Coverage Amount*
Liability Protection Limit*
Liability Protection Limits
$1,000,000
$500,000
$300,000
$100,000
Medical Coverage*
Medical Coverage
$50,000
$25,000
$10,000
$5000
$2000
$1000
Sump/Water Back-Up Limit*
Monitored Burglar Alarm?*
Monitored Burglar Alarm?
Yes Monitored
Yes Non-Monitored
No
Fire Extinguisher(s)*
Fire Extinguisher(s)?
Yes
No
Dead Bolt Locks?*
Dead Bolt Locks?
Yes
No
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
Are you interested in the extra coverage rider for Sump Pump/Sewer Water Back Up?*
Yes
No
Current Mortgage Co Name, Address, Loan#*
Insurance premium escrowed?*
Insurance premium escrowed?
Yes
No
If you have a mortgage, what is the balance and numbers of years left on it?*
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?*
Cancelled or NonRenewed?
Yes
No
If Yes, provide reason
May we help you in any other way?
Would you like an AUTO quote? Check YES and complete AUTO quote form
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 credit score histories, to calculate an accurate price for your insurance. You also agree for us to contact you via telephone, email, mail or text regarding this quote, even if you are on the Do Not Call or Do Not Contact/Mail listing.
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