Homeowner's Insurance Quote Request provided by Farmer Group, Inc.

If you have more than 1 residence, please fill out another form

Please Note: Insurance coverage cannot be bound without a written binder from our office.

Please Also Note: Many insurance carriers use information gathered from you and outside sources about your claim, credit history and home. This information allows insurance companies to determine accurately the proper price to charge. You are entitled to a free copy of the reports by contacting the appropriate consumer reporting agency within the next 60 days.

By filling out this form, you agree to the above terms.

ABOUT YOU
What is your name? -------------------------------------------------------------------------
Last
First
Middle
What is your mailing address? ----------------------------------------------------------
Street
City
State
Zip
How may we contact you? -----------------------------------------------------------------
Home Phone
Work Phone
Fax #
Email
Other Personal Information ------------------------------------------------------------
Date of Birth
SSN

PROPERTY INFORMATION
What is the property address? ----------------------------------------------------------
Street
City
State
Zip
What is your mortgage balance?
What is the replacement cost of your home?
Number of families?
What is the dwelling type?
How many bedrooms are there?
How many bathrooms are there?
Number of Half Bathrooms
How many fireplaces are there?
How many porches or decks are there?
Square Footage of Porch/Deck
What year was it built?
What date was the property purchased?
What is the construction type?
How many stories?
If two stories, what is the ground floor square footage?
What is the total square footage of the building?
What foundation type?
What type of garage?
What type roof covering?
Was the roof updated?	Yes No
If yes, what year?
Do you have a pool?	yes no

Does the building have a pool?	Yes No
Is the pool fenced?	Yes No
Is the fence lockable?	Yes No
Is there a diving board?	Yes No
Is there a slide?	Yes No

What is the distance of fire protection from the building?

Is there a smoke alarm?	Yes No
Is there a fire extinguisher?	Yes No
Are there deadbolts?	Yes No
Is the electrical updated?
Are there circuit breakers?	Yes No
Do you have central air?	Yes No
How old is the heating/ air conditioning?
Has the plumbing been updated?	Yes No
Is there a theft alarm?	Yes No
Is there a fire alarm?	Yes No
Are the alarms Monitored?	Yes No
Do you have a trampoline?	Yes No
Number of acres dwelling is located on:
Are there dogs on the property?	Yes No
If yes, how many and what is the breed of each dog?	200 character limit please
Are there any other pets or animals on the property?	Yes No
If yes, how many and what is the description of each?	200 character limit please

CURRENT COVERAGE INFORMATION
What is the current insurance company?
What is the expiration date of current policy?
Where there any losses or claims in the last 5 years?	Yes No
If yes, what is the date, amount paid and description of each loss or claim?	200 character limit please

DESIRED COVERAGE INFORMATION
Dwelling Amount	Coverage A
Other Structures	Coverage B
Personal Property	Coverage C
Loss of Use	Coverage D
Premise Liability	Coverage E
Policy Deductible	Amount
If earthquake insurance is requested, select deductible percentage %	Earthquake Deductible
List the value of property used for business. If the value is over $1000, list the value of Guns, Jewelry, Firearms, or Fine Art.		200 character limit please
Should we provide a seperate quote for flood insurance? This is not covered under a homeowner's policy.		Yes No
QUESTIONS OR COMMENTS:
200 character limit please
If you have more than 1 residence, please fill out another form Please Note: Insurance coverage cannot be bound without a written binder from our office. Please Also Note: Many insurance carriers use information gathered from you and outside sources about your claim, credit history and home. This information allows insurance companies to determine accurately the proper price to charge. You are entitled to a free copy of the reports by contacting the appropriate consumer reporting agency within the next 60 days. By filling out this form, you agree to the above terms.