Home/Condo/Rental Property Insurance Quote Form
Please
fill out as much information as possible. Please contact
us with any questions about this form.
|
| PERSONAL
INFORMATION |
| Name: |
|
| Street
Address: |
|
| City,
State, Zip Code: |
|
| Preferred
method of contact: |
|
|
E-mail: |
|
|
Telephone: |
|
|
Fax: |
|
| |
|
| HOME/CONDO/RENTAL
PROPERTY/ INFORMATION |
| Street
Address (if different
than above): |
|
| City,
State, Zip Code: |
|
| Year
Built: |
|
| Square
Footage: |
|
| #
of Bathrooms: |
|
| Roof
Type: |
|
| Year
the roof was installed: |
|
| #
of Stories: |
|
| Type
of Garage: |
|
| Type
of Construction: |
|
| Alarm
Type: |
|
| Have
there been any claims in the last
three years?
Yes
No |
| If
yes, please
list all claims in the last three years, including dates and
amount paid: |
|
| Dwelling: |
|
| Contents: |
(at least 50% of the Dwelling) |
| Other
Structures: |
(at least 10% of the Dwelling) |
| Loss
of Use: |
(at least 20% of the Dwelling) |
| Liability: |
|
| Medical
Payments: |
|
| Deductible: |
|
| Do
you want to itemize any jewelry, furs, silverware, guns, golf clubs,
collectibles, or fine arts?
Yes
No |
| If
yes, please
list the total value of each catagory (ex. jewelry $3,500 &
silverware $2,000):: |
|
| |
|
| UMBRELLA
POLICY (OPTIONAL) |
| Are
you interested in a Umbrella Policy?
Yes
No |
| If
yes, complete the following: |
|
| #
of cars: |
|
| #
of boats: |
|
| #
of houses: |
|
| #
of drivers in the household: |
|
| Umbrella
Limit: |
|
| |
|
| FLOOD
POLICY (OPTIONAL) |
| Are
you interested in a Flood Policy?
Yes
No |
| |
|
|
|
|
| Submitting an insurance quotation request
to Alexander & Strunk Insurance does not constitute a binding confirmation
of new or altered insurance coverage. Verbal and/or written confirmation
must be obtained from Alexander & Strunk Insurance to confirm binding or altering
coverage. |
