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Dan's Home Quotes


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Personal Information
First Name
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Last Name
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Street
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City
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State
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ZIP / Postal Code
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Primary Phone Number
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E-Mail Address
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How did you hear about us?
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Desired effective date?
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Any claims in the last 5 years? If so, please describe
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Your Date of Birth?
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Social Security Number - (our system is secure)
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Occupation
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Current insurance company name
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Desired effective date?
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If no insurance - please list reason below
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Current auto insurance company (discounts may apply)
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Current Limit on Dwelling and Contents
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Deductible
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Square Footage of Building
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Year Built
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Any pets? If so, describe
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How would you decsribe your house type?
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If you have a basement - is it finished?
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Construction type
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Roof Type
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Age of Roof
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Number of Stories Including Basement
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Age of Electric?
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Type of wiring
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Alarm System?
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Any business conducted on premises?
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If yes, please descibe
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Any porches or decks?
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Fireplace or other heat source?
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Flooring - pick all that apply through whole house
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Garage?
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Heat Type
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Interior walls
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Kitchen - choose all that apply
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Number of full baths?
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Number of half baths?
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Swimming pool?
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Age of Plumbing
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Would you like to schedule jewelry / guns / silver / art or other? If so - describe
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Any other features?
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If yes, please descibe
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Do you need water back up?
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Do you need flood insurance?
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Do you have a Mortgage? If so, amount
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Should we quote an Umbrella for you?
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When is the last time you reviewed your Life Insurance?
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

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