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Homeowners Quote Request Form

Applicant Information:

Name: 

Address:

City:

State:

OKLAHOMA

Zip:

Phone:

EMAIL:

Date of Birth:

Your occupation:

Current Insurance Information:

Current Insurer:

Policy Exp. Date:

Amt. Insured for:

Mortgage Amt:

Premium Amt:

Have you been cancelled/nonrenewed:

Yes

No

Losses in Past 3 Years/Amount Paid:

Dwelling Information:  (Complete if you live outside Oklahoma County)

Year Built:

Construction

Roof Type

Age of Roof

Miles from Fire Station

Feet from Hydrant

Garage

Alarm

Stories:

Sq Ft of 1st Floor

Fireplace

Baths

# of Bedrooms

Heating System

Coverage Limits

 

Yes

No

Pool or Hot Tub?

 

 

     Diving Board?

 

 

     Pool fenced?

 

 

Inside City Limits?

 

 

Enclosed Porch or Deck?

 

 

Daycare on Premises?

 

 

Dog or Pets?

 

 

House visable to neighbors?

 

 

Non-Smoker?

 

 

Business out of home?

 

 

Domestic Employees?

 

 

Monitored Security System?

 

 

Monitored Fire Alarm:

 

 

Smoke Detector?

 

 

Replacement Cost of Dwelling :

Replacement Cost of Contents:

                       Liability Limits:

                                     Medical:

   Antiques/Collectables Value:

                       Cameras Value:

                 Coin/Stamp Value:

   Computer Equipment Value:

                     Fine Arts Value:

                             Furs Value:

                           Guns Value:

                       Jewelry Value:

                         Silver Value:

Additional Information or comments:

Please Note: To offer you accurate quotes,  insurance companies may collect information from consumer reporting agencies, such as driving record, claims, or credit history reports.