H
omeowners
Q
uote
F
orm
Please fill out all sections highlighed in yellow and push the submit button when you are finished.
Name:
Address:
City:
Country:
State:
Pennsylvania
Home Telephone Number:
Work Telephone Number:
Cell Phone:
Fax Number:
Email Address:
Spouse's Name:
Social Security Number:
Date of Birth:
*mm/dd/yyyy
Number Stories:
Square Footage:
Year Built:
Construction Type:
Is this property your primary residence?
Yes
No
Number of families living at this residence:
Do you have a swimming pool?
Yes
No
Do you have pets or animals?
Yes
No
If yes, Please state number of pets and types of pets in the household:
Are there any woodburning stoves, fireplace inserts, woodburning furnaces, space heaters, or kerosene heaters on the premises?
Yes
No
Basement:
Yes
No
Finished
Unfinished
Type of Home:
Single
Twin
Row
Duplex
Amount of Insurance Requested
Dwelling (excluding land):
$
Personal Property:
$
Personal Liability:
----- Select -----
$100,000
$300,000
$500,000
Medical Payments to Others:
----- Select -----
$1,000 each person
$2,000 each person
$3,000 each person
$4,000 each person
$5,000 each person
Please list all claims for the prior 5 years:
Has the house ever been updated for the following:
Electrical:
Yes
No
Approximate Date:
Type of Electrical Service:
Fuse
Circuit Breakers
Plumbing:
Yes
No
Approximate Date:
Type of Heating Service:
Gas Forced Air
Gas Hot Water
Oil Heat
Propane
Other Please List:
Year Heater Was Updated:
Roof:
Yes
No
Approximate Date:
Additional Coverage Requested:
Dwelling Replacement Cost Guarantee:
Yes
No
Replacement Cost Personal Property:
Yes
No
Ordinance or Law Coverage:
Yes
No
Earthquake Coverage:
Yes
No
Umbrella Liability:
Yes
No
Has any company declined, cancelled, or refused to renew any similar insurance:
Yes
No
If yes, explain:
Have you ever had any loss such as fire, windstorm, theft, liability, etc. on this or any other property during the prior 5 years:
Yes
No
If yes, explain:
What is the expiration date of your current policy?
How Did You Hear About Us?
Additional Comments:
How do you want to recieve your quote?
Via E-mail
Fax
Telephone
Online Help Desk
Peterson Insurance Services, Inc.
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