Homeowner’s Insurance Request Request coverage on your home with the form below. Your Personal Info Your Name (required) Your Email (required) Your Phone Number Street Address City Zip County The Dwelling Info Year Built Square Footage [number dwelling-squareFootage Is there Builder's Risk? [radio dwelling-builderRisk use_label_element default:1 "Yes" "No"] Month and Year to be completed Number of units: Single FamilyDuplexTriplexQuadplexOther Foundation type: SlabCrawlspace over slabPier & Postother Type Construction: Frame, Brick/Veneer, Stone, Other (list in remarks) FrameBrick/VeneerStoneOther Type of Roof: ShingleWood ShakeTar/GravelSpanish TileMetalOther Number of stories: One1.5TwoThreeMore than threeOne1.5TwoThreeMore than three Do you own animals or pets? YesNo If you own dogs, please list breeds: Are You Near Brush Area? YesNo How many feet from the nearest fire hydrant? How many miles from the nearest fire station? Is there a Garage? YesNo How many cars is the garage? Is the garage built in, detached/attached? Currently Insured? Yes No YesNo If the dwelling is currently insured, please provide the Name of carrier & how long insured? Prior Claims? Yes No YesNo Describe prior claims in detail: Rate Your Credit History and Past Insurance Payment History: (Some companies products are based on your credit and payment history.) ExcellentFairPoorHorrible Primary Policyholder's Birthdate: (Some companies products offer discounts for certain age groups.) Plumbing type: CopperGalvanizedMixed (Copper/Galvanized)Other Heating Type: Gas (propane or natural)ElectricOil If the dwelling is heated with oil, where is the oil tank located? Circuit Breakers or fuses? Breakers Fuses Circuit BreakerFuses How many Bedrooms? How many Bathrooms? How many Fireplaces? How many Chimneys? Special features: (i.e., deck, air conditioning, alarm systems, pool, etc.) Dollar Amount of Coverage What is the dollar amount of dwelling coverage you are requesting? What is the dollar amount of contents coverage you are requesting? What is the dollar amount of liability coverage you are requesting? How much would you like your deductible to be? Comments/Remarks: (describe any scheduled jewelry, in-home business, or other special coverages/remarks here):