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Request a Homeowner's Insurance Quote
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Please complete and submit
the form below if you would like to obtain a
quote on Homeowners Insurance. This is for quote
purposes only and in no way acts as an
application or binder of insurance. If coverage
is desired, an application will be sent to you.
All information provided by
you is confidential and will be used solely for
the purpose of providing you with a Homeowner's
Quote.
To provide the most accurate quote, please
provide your Social Security Number and your Date of Birth.
To properly quote this insurance, it may become
necessary to obtain a consumer report on your
behalf. By providing the information requested
below, you authorize Independent Insurance Associates to
order/obtain and review this report.
If you would prefer to not fill out the form in
it's entirety, feel free to contact us or
complete only the Personal Information section and
click the submit button at the bottom. One
of our agents will contact you within two
business days.
Press the 'Tab' key (NOT the 'Enter'
key) to move through the form.
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Personal Information |
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Full Name:
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Address:
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Daytime Phone Number:
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(include extension)
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Evening Phone Number:
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(include extension)
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Best Time to Call:
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Email Address:
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Preferred Method of Contact:
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Occupation:
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How Long at Present Job:
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years
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SS/SIN Number:
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Time at Present Address:
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# of Claims Last 5 Years:
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Have you had any judgments, liens, or bankruptcies in
the last 7 years?
If you are a resident of California, please do not
answer this question. |
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If 'Yes',
please explain below:
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Current Insurance Information |
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Current Insurance Company:
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Policy Expiration:
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Premium Amount:
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(optional)
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Continuously Insured for Last:
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Have you ever had insurance
cancelled, denied, or
non-renewed? |
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If
'Yes', please explain below:
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Structure Information |
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House Type:
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Year Home was Built:
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Square Feet:
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Construction:
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Foundation:
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Roof Type:
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Roof Age, in years:
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Garage Size:
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Garage Type:
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Square Footage of Deck:
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Square Footage of Porch:
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Square Footage of Patio:
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# of Fireplace Chimneys:
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# of Fireplace Hearths:
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# of Full Bathrooms:
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# of Half Bathrooms:
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Basement Finish:
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Total Basement Square Footage:
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Additional Features |
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Heating System:
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Central Air:
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Central Vacuum:
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Security Alarm:
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Fire Alarm:
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Smoke Detectors:
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Pets |
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Do You Have Any Pets?
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If 'Yes' please completely describe all of
your pets below. Please
include Type and Breed for each pet you have. |
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Coverage Desired |
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Coverage Amount on House:
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$
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Amount on Contents:
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$
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Amount for Other Structures:
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$
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Deductible Amount:
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Liability Amount:
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Additional Comments / Additional Information
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