Florida Homeowners Insurance Quote

Full Name:          
Address to be Insured:
City:
Florida
Zip Code:
Email Address: (Required) 
Home Phone:   Work Phone:   Ext.
How to Contact You: Select One Phone at Work Phone at Home Cell Phone Email       Cell Phone:
Date of Birth:              (mm/dd/yyyy)
Social Security #:       

Spouse Name:             
Date of Birth:              (mm/dd/yyyy)
Social Security #:       

Do you currently have Florida Flood Insurance? Select One Yes NO
Do you currently have FL Homeowners Insurance? Select One Yes No
Coverage requested for? Select One Primary Home Second Home Condominium Apartment Townhouse Other
Usage Type: Select One Primary Home Seasonal Rental Farm Vacant Other
Years Lived at Address to be Insured:   Select One Less than 1 1 to 2 years 2 to 5 years Over 5 years New Purchase

Florida Homeowner Insurance Coverages & Limits of Liability:

Dwelling ($ value):
Additional Structures ($ value):
Personal Property ($ value):    

Personal Liability (each occurence): Select One $100,000 $300,000 $500,000
Medical Payments (each person):    Select One $1,000 $5,000 $10,000
Other Perils Deductible: Select One $2,500 1% 2% 5%
Windstorm Deductible: Select One 2% 3% 5% Exclude Wind

Policy Endorsements:

Replacement Cost, Dwelling: Yes No
Replacement Cost, Contents: Yes No

Florida Homeowner Insurance - Dwelling Information:

Building Structure: Required-Please Select Frame Hardi Plank Brick Veneer Stucco
Year Dwelling Built:     Dwelling Square Feet:
Smoke Detectors?   Select One Yes No           Deadbolt Locks?     Select One Yes No
Central Burglar Alarm?  Select One No Local Monitored     Central Fire Alarm? Select One No Local Monitored
Sprinklered All Rooms? Select One Yes No
Primary Heat Type: Select One Central Floor Furnace Wood Stove
Do you have a Wood Stove? If yes, is it on a separate flue? Select Yes No

Fireplace:  Select One Yes No
Full Baths: Select One 1 2 3 4     Half Baths:    Select One None 1 2
Garage:     Select One Attached Unattached None     Garage Size: Select One 1 car 2 car 3 car 4 car
Basement: Select One Yes No

Type of Wiring:          Select One Circuit Breakers Knob & Tube Fuses Other
Wiring Renovation:     Select One None Partial Complete     Wiring Renovation Year:   
Plumbing Renovation: Select One None Partial Complete     Plumbing Renovation Year:
Heating Renovation:   Select One None Partial Complete     Heating Renovation Year:  
Roofing Renovation:   Select One Partial Complete     Roofing Renovation Year:  
Roof Type: Select One Composition Wood Tile Metal     Roof Age (years):
Exterior Paint Renovation: Select One None Partial Complete     Exterior Paint Renovation Year:

Dwelling Distance from Fire Department:  miles
Dwelling Occupied By: Select One Owner Tenant
Swimming Pool:     Select One Above Ground In-Ground None          Diving Board:   Select One Yes No
Pool Screened:      Select One Yes No          Approved Fence:   Select One Yes No

Loss History:

Did you have any losses, whether or not paid by insurance, during
the last 3 years, at this dwelling location or any other location? Select One Yes No
If the answer to the previous question was "Yes", please explain below.

Date                            Type                      Description of Loss           Loss Amount
      
      
      

Additional Information or Comments



Click on the "Submit Quote Request" button below to send
your Florida Homeowner Insurance quote request.**

**Information received from this Florida Homeowner Insurance quote request
form sent to "YOUR AGENCY NAME" will be for our use only and will not be sold,
given to or distributed to any other parties. A quote will be based on the Florida
homeowner insurance policy information provided and does not guarantee
acceptance of the risk by us. The precise coverage afforded is subject to
meeting underwriting guidelines, and the terms, conditions and exclusions of
the policy as issued. By submitting this request you acknowledge that this is
neither an offer to insure nor a guarantee of insurance. Completion of this
form does not entitle you to a Florida Homeowner Insurance policy. We are
licensed in Florida and will not provide homeowner quotes for other states.

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