homeowners quote form fax to (574) 296-6611

By
Services for Real Estate Pros with Brooke Insurance

Homeowners Quote Request Form


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* = Required Fields

 

Homeowner/Contact Information

* Todays Date:
(mm/dd/yyyy)
* Owner's First Name: * Owner's Last Name:
* Street Address: * City:
* State: AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY * Zip:
* County: * Valid Email Address:
* Home Phone:
(999-999-9999)
* Work Phone:
(999-999-9999)
* Owner's Date of Birth:
(mm/dd/yyyy)
* Owner's Gender: Male Female
Owner's Social Security Number:
(e.g. 555-55-5555l)
* How would you (owner) describe your credit rating?: Poor
Good
Excellent
Unsure
* Current Residence Status: Own Rent Live With Parents Dormitory Choice Not Listed * Length of time at current residence?:

* Best time to contact you?:

* Best way to contact you?:

Anytime Morning Afternoon Evening

Email Phone
Work Phone

* How quickly do you need your request processed?: ASAP 1 Day 2 Days 3 Days 4 Days 5 Days 6 Days 1 Week
Please provide any comments you have: Are you interested in a multiple-policy discount (for auto and home insurance)?: Yes No
* Are you currently (or have you ever been) a Brooke customer? Yes No * How did you hear about Brooke?
Insurance Information
Please tell us more about your current or recent insurance policy. Be as accurate as possible.
* Your most current insurance company: * What date does your current policy expire/renew?
(mm/dd/yyyy)
* How long have you been insured with your current insurance company?: * How long have you been continuously insured with this company?
Property Location and Type
* Address of the property to be quoted: Address 2 or Apt. Number:
* City/Township: * County/Parish:
* State: AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY * Zip Code:
* Please select the property type: Single Family Home Multi Family Home Apartment Duplex Condominium Townhome Mobile Home Other * Do you currently own (or are you in the process of purchasing) this property?: Yes No
* Do you now reside, or plan on residing at this property within the next 12 months?: Yes No
Property Coverage Information
* How much Residence coverage do you want?:
(In dollars, for example: 250,000)
* How much personal liability coverage do you want?: 100,000 300,000 500,000 1,000,000
* How much deductible?:
(The higher your deductible, the lower your premiums)
100 250 500 1000 2000 * Approximate year property built:
* Approximate livable square footage of residence:
(excluding basement, if any)
* Is this your primary or secondary residence?: Primary Secondary
* Is business or farming conducted on this property?: Yes No * Do you have any of the following breeds of dogs: Chow, Doberman, German Shepherd, Pit Bull, Rottweiler, Wolf Hybrid, or mix of these?: Yes No
* Dwelling design: One Story Bi Level Two Story Tri Level Other * Exterior wall type:
(60% or more)
Aluminum or Vinyl Siding Mostly Brick Mostly Wood Frame Stucco Cinder Block Mostly Stone Veneer Log Other
* Number of Bedrooms: 1 2 3 4 5 6 7+ * Number of Bathrooms : 1 1.5 2 2.5 3 3.5 4+
* Roof Type: Composition Shingle Tile Wood Shingle Concrete Other * Roof Age: 1-5 years 6-10 years 11+ years
* Garage Type: Attached - 1 Car Attached - 2 Car Attached - 3 Car Attached - Carport Detached - 1 Car Detached - 2 Car Detached - 3 Car Detached - Carport No Garage Other * Describe Foundation or Basement: Bsmt Fully Finished Bsmt 3/4 Finished Bsmt 1/2 Finished Bsmt 1/4 Finished Bsmt Unfinished Crawl Space Piers Pilings Stilts Slab Other
* Wiring Type: Copper Aluminum Knob and Tube Unknown * Service Panel Type: Circuit Breaker Fuse Box Unknown Other
* Central Burglar Alarm: None Monitored Unmonitored * Central Fire Alarm: None Monitored Unmonitored
* Fire Station: Within 5 Miles Within 10 Miles Over 10 Miles * Fire Hydrant: Within 1000 Feet Over 1000 Feet
* Municipal Location: Inside City Limits Outside City Limits * Please describe the heating system in this dwelling: Gas (Forced Air) Electric Boiler Oil/Coal/Kerosene Propane Stove Unknown Other
* Number of gas, pellet or wood fireplaces or stoves: 0 1 2 3 4 5 * Is your home prone to flooding or located in a designated flood plain?: Not Applicable Designated Flood Plain Prone to Flooding
* Property Accessories
Dead Bolts Air Conditioning Tennis Court
Smoke Detectors Covered Deck/Patio Trampoline
Fire Extinguisher Uncovered Deck/Patio  
Indoor Fire Sprinkler Swimming Pool  
Claims Information
Claim Type: Fire or Lightning Damage Windstorm or Hail Damage Ice Snow Sleet Damage Smoke Damage Water Damage Vandalism Theft Loss Claim Not Listed Date of Claim:
(mm/dd/yyyy)
Claim Type: Fire or Lightning Damage Windstorm or Hail Damage Ice Snow Sleet Damage Smoke Damage Water Damage Vandalism Theft Loss Claim Not Listed Date of Claim:
(mm/dd/yyyy)
Claim Type: Fire or Lightning Damage Windstorm or Hail Damage Ice Snow Sleet Damage Smoke Damage Water Damage Vandalism Theft Loss Claim Not Listed Date of Claim:
(mm/dd/yyyy)

 

 
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Anonymous
Can I get a Workers Comp Quote from you?
We are shopping our rates for Workers Comp. We have 10 employees and no claims. Is there a form that we can fill out online to get the quote?
Jan 31, 2008 03:51 AM #1
Anonymous
I need contractors insurance
I need contractors insurance for a bid job that im doing. I just started my company and I am the only employee. I will be snow plowing in the winter and painting homes in the summer. Can I have one insurance policy even though my job description is in two SIC codes?
Jan 31, 2008 03:54 AM #2
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