HOME  |  CONTACT US

Insurance Associates Home
Advice. Solutions. Peace of Mind.

Businesses & Organizations

Individuals & Families

24-Hour Claims Service

Agency Information

Community Involvement

Library/Links

 
Home Quote
 
 Policy Holder
  Contact Name *
  Date of Birth *
  Social Security Number
  Email *
  Phone Number
 
 Property Location
  Address
  City
  State
  Zip
  County
 
 Current Insurance Information
  Company Name
  Current Annual Premium
  Expiration Date
  Deductible Desired
  Amount of Liability
  Earthquake Coverage Desired? Yes  No
  Have you filed for bankruptcy within the past 7 years? Yes  No
 
 Dwelling Information
  Estimated Replacement Cost-Dwelling
  Square Footage
  Year Constructed
  How Many Floors? 1 Story
1.5 Story
2 Story
Bi-Level
Tri-Level
Other 
  Type of Construction

 

 

 

Basement Finished

Wood
Stucco
Masonry
Brick Veneer
Aluminum Siding
Other 

Yes No

  Other Features
  (check all that apply)

 

 

 

 

 

Pets/Farming/Livestock (Please List)

 

Dead Bolts
Smoke Detectors
Fire Extinguisher
Central Station Fire Alarm
Central Station Burglar Alarm
Home Located within 5 miles of Fire Station
Home Located within 1000 feet of a Fire Hydrant
Swimming Pool
Trampoline
Home located within City Limits

 
 Claims
   List any claims in past 3 years:
  Date of Claim Amount Paid Claim Type Description
1.
2.
3.
 
 Personal Property
   Estimated value of your personal property:
  Jewelry & Watches
  Furs
  Silver
  Firearms
  Stamp and Coin Collections
  Fine Arts and Breakable Item
  * indicates required fields
Other Items you would like us to quote (please list)        
Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.
 

 

| Home | Contact Us |