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HOMEOWNERS Insurance Quote Form
(Please Enter Your Information Below)

How would you like to be contacted with your quote?

E-mail
Phone
Fax

Information For Homeowners Insurance

Name:
Address:
City:
County:
State:
Zip:
Phone:
Fax:
E-mail:

House Type (Select One)

Single Family
2-4 Family
Townhouse

Construction Type (Select One)

Frame
Brick/Masonry
Veneer

Year Built:
Insured Value:

Property Deductible:

$100
$250
$500
$1000

Contents Value:

Liability Limit:

$100,000
$300,000
$500,000
$1,000,000

Medical Expense:

$1000
$2000
$5000
$10,000

 

Dead Bolts:
Yes No
Smoke Alarm:
Yes No
Fire Extinguisher:
Yes No
Non-Smoker:
Yes No
Burglar Alarm:
Yes No
Fire Alarm:
Yes No
Central Station Burglar:
Yes No
Central Station Fire:
Yes No
Insured Over 55:
Yes No
Are you currently insured:
Yes No

 

Please provide details for any losses which have occurred in the past three (3) years:

Loss Description:

Amount Loss Description:

Amount:

Comments:

Stephen F. Butz
Vice-President Personal Lines

Stephen's profile...

Tracy Schmitz
Producer

Tracy's profile...

Vicky Shrum
Producer

Vicky's profile...

Tom Jokerst
Producer

Tom's profile...

Mike Tucker
Producer

Mike's profile...

Customer Service Representatives (CSR):

Shirley Graue
CSR

Mary Roberts
CSR

Julie Mana
CSR

REPRESENTING:

Electric
Encompass
Hartford
Hawkeye
MetLife
Ohio Casualty
Progressive
Safeco
State Auto
Travelers

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