Smith & Associates / Bardstown_14-0012-00

Home Insurance Quote

Please complete the form accurately for better assistance
Name*

PrefixFirst NameLast Name
E-mail*
Date of Birth*

MonthDayYear
Phone Number

Area CodePhone Number
Address of Home to Insure*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Social Security #
Policy Qualification Questions
Is this home a new Purchase? *

YesNo
If yes... Is the home a "foreclosure" or "short-sale"?

YesNo
If you already own the home... is the home currently insured?

YesNo
Additional Questions:
Is this house your primary residence?*

YesNo
If no... Is the home Seasonal, Vacant or Rental Property?
What year was the home built? - (feel free to estimate)*
Is the construction of the home BLOCK or FRAME?*
What year was the roof last replaced? - (feel free to estimate)
What is the Square footage of your home?
Is the home 1 or 2 story?

1 story2 story
Is there a basement

YESNO
If so what percent is finished
Is there Central heat and air?

YESNO
Are there any alternative heat sources such as wood stove?
Is there an attached garage?

YESNO
If so, How many cars ?
Is there a detached garage?

YESNO
if so what’s the construction and square footage?
Is there a pool or trampoline on premises?

YESNO
If so is it fenced?

YESNO
Is any part of the roof flat?*

YesNo
Have you had any bankruptcies, foreclosures or repossessions in the past 5 years?*

YesNo
Have you had a claim on any property in the last 5 years?*

YesNo
Do you own any of the following dogs: Pit Bull, Rottweiler, Doberman, Akita, Chow, German Shepard, Staffordshire or Terrier?*

Yes (... & I luv my pup)No
Is there a fire hydrant within 1000 feet of your home?

YesNo
How would you like us to contact you regarding this quote?
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Home Insurance Quote