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Home Quote Questionaire
Date picker
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First name
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Last name
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Email
*
Phone
*
Birthday
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Month
Day
Year
Multi-line address
Country/Region
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Address
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City
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Zip / Postal code
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Insured Property Address
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Date Property or Home Purchased
What year was the home built?
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Is your home a mobile home? Is it a single or double?
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Yes
No
Single
Double
What is the square footage of the home?
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How many stories?
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How many bathrooms?
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Are there any porches or decks? If yes, please list sizes of each. If no, please respond N/A
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Frame or Brick?
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Frame
Brick
Do you have central air?
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Yes
No
Do you have a garage?
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Yes
No
Is the garage....?
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Detached
Attached
No Garage
Do you want the garage covered in the policy?
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Yes
No
No Garage
Are there any other structures on the property? If yes please list type, size, and if you'd like it covered in the policy.
Do you have...?
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Basement
Crawl
Slab
If you chose basement is it...?
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Finished
Unfinished
No Basement
Heat Type
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How is your heat controlled?
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When was the heat last updated?
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Do you use supplemental heat? If yes list the type and when it was last updated. If no please put N/A.
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What type of plumbing do you have? Please list type and when it was last updated.
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What type of electric do you have? Please list type and when it was last updated.
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What is your roof made out of? Please list type and date last updated.
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Dwelling Amount
*
Liability Amount
*
Do you have dogs? If yes, please list breed, age, and if they have a bite history.
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Do you have a pool?
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Yes
No
Is the pool above or below ground?
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Above
Below
No Pool
Is the pool fenced?
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Yes
No
No Pool
Do you have a trampoline?
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Yes
No
Nearest fire department?
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Distance from home?
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Nearest fire hydrant?
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Do you have a central alarm system?
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Yes
No
Do you have smoke alarms?
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Yes
No
Do you have morgagee? If yes please list name and address.
*
Who is your current insurance provider? Please list name and current premium.
*
How did you hear about us?
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Facebook
Instagram
Tiktok
Google
Ad
Friend/Reletive
Other
If other or friend/relative please list how you found us or the name of the person who referred you. If no, please respond N/A.
*
Submit
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