Request for Quotation - Homeowner's Insurance

Fill out and submit this form and a representative of
The Insurance Center
will contact you within one working day.

All information is treated as confidential and is for internal use only. Your email address won't be sold or passed on to anyone outside our office.

Full Name: *
State: Zip:
Prior address if less than three years:  
State: Zip:
Home Phone: *
Work Phone:
Email: *
Date of Birth:  MM/DD/YY
Are You Currently Insured? Yes  No
If Yes, what company:
What is your premium & expiration date:  MM/DD/YY

* = Required items

Dwelling Information

No. of Stories: Square Footage:
Year Built: No. of Bedrooms:
Year moved in: No. of Bathrooms: Full: Half:
Age - Roof: Age - Electrical:
Age - Heating: Type: gas, oil, electric
Age - Plumbing: Type: galvanized, copper, plastic
No. of Families: Hydrants: Yes No

Do you have –      
Circuit breakers: Yes No Trampoline: Yes No
Siding: Yes No Dead bolt on all doors: Yes No
Dining room: Yes No Family / Rec room: Yes No
Basement: Yes No Attic: Yes No
Finished basement: Yes No Finished attic: Yes No
Foyer or Entrance hall: Yes No Walk-in closets: Yes No
Fire extinguisher: Yes No Smokers: Yes No
Fireplace: Yes No Smoke alarm: Yes No
Home business: Yes No Wood burning stove: Yes No
Farming exp: Yes No Laundry room: Yes No
If Yes, No. of Acres: Satellite dish: Yes No

Miles to Fire Dept: Hydrants: Yes No
Porch / deck: Yes No Porch / deck size:
Garage / barn:Yes No Garage / barn size:
Attached garage: Yes No    
Central Air Conditioning: Yes No    
Dogs: Yes No Breed:
Pool: Yes No Above ground: Yes No
In-ground Yes No Fenced: Yes No

Desired Coverage

Dwelling: Deductible:
Contents/Per. Property Medical Payments:
Liability limit:    
Additional coverage:      
Umbrella: Water / Sewer backup:
Flood damage: Earthquake:
Special coverage: Amount    
Jewelry: Boats:
Silverware: Computers:
Furs: Guns:

Additional Data

Any losses in the last five years? Yes No Amount:
Describe losses:
Any additional features?
Mortgage clause?
Escrow billed Yes No Binder Yes No

Did you know that you can save as much as 10% on your
Home or Renter's insurance if we also write your Auto insurance?
Click this link to request a quote on Auto insurance.


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Page last reviewed: 21 Feb 07
© 2003-2007 Stephen M. Hawley & Assoc., LLC