Homeowners Insurance Quotation Form One Simple Form - takes only 2-3 Minutes! Your Personal Data:   Your Name: Property Address: City: Your "County" is? State: (Must be Rhode Island) Zip/Postal: E-Mail (REQUIRED): E-Mail again for accuracy: Phone: Fax (optional):     Dwelling Information   Year Home Built: Home Square footage:   Is this Builder's Risk? (new home constr.) NO YES   Month/Year home to be complete:   Number of units: 1 family Duplex   Type foundation: Slab Crawlspace over slab Pier & Post Other (list in remarks)   Type Construction: Frame Brick/Veneer Stone Other (list in remarks)   Type Roof: Shingle Wood Shake Tar/Gravel Spanish Tile Metal Other   Number of stories: One 1.5 Two Three   Do you own animals or pets? Yes No If yes, list type/for dogs, list breed:   Are You Near Brush Area? Yes No   # of feet to nearest fire hydrant: # of miles to nearest fire station:   Does Home Have a Garage? Yes No Tell whether built in, detached/attached, and how many cars?   Currently Insured? Yes No Name of Carrier & how long insured?   Prior Claims? Yes No Describe claims in detail:   Rate Your Credit History and Past Insurance Payment History: (Some companies products are based on your credit and payment history.) Excellent Fair Poor Horrible   Primary Policyholder's Birthdate: (Some companies products offer discounts for certain age groups.)   Plumbing type: Copper Galvanized Mixed (Copper/Galvanized)     Heating Type: Gas (Propane or natural) Electric Oil (if oil, list tank location in remarks)   Circuit Breakers or fuses? Breakers Fuses # Bedrooms: # Bathrooms:   # Fireplaces: # Chimneys:   Special features (i.e., deck, air conditioning, alarm systems, pool, etc.)   Coverages:   Dwelling Cov. $ Contents $ Liability Cov. $ Deductible $ ($250, $500, $1,000, etc.)   Comments/Remarks (describe any scheduled jewelry, in-home business, oil tank location, or other special coverages/remarks here):   Send my quotation via: E-Mail Fax Regular Mail Call Me By Phone Thank you for filling out this form COMPLETELY! We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy. Yes, I Agree. Please Send Me a Quote NOW! Click Button Below When Done Please Click Only Once . . . May take up to 30 seconds!
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