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101

 

Homeowners Insurance Quote Form



Personal Information
Full Name:
Address:
City:   State:   Zip:
Daytime Phone:   Night Phone:
E-mail Address:
Occupation:   How long at current job:

Current Homeowners Insurance Information
Company Name
(not agency):
Policy Expiration Date:   Premium Amount: $
Amount Insured For: $     Policy Type: Primary Secondary
Purchase Price: $
Loan Amount: $

Home Information
Year Home Was Built:
No. of claims In Last 3 Years:
Sq. Footage (excluding garage & basement): sq. ft.        
Structure Information
Type
Construction
Roof
Foundation
Garage
Roof age:yrs.
Features
Bathrooms
Basement
Deck/Porch/Patio
Fireplaces
No. of Full:
No. of Half:

Sq. Ft.:
Deck Sq. Ft.:    
Porch Sq. Ft.:    
Screened Patio Sq. Ft.:     		Chimneys:
No. of Hearths:
Additional Features
Heating System
Central Air
Central Vac
Security Alarm
Fire Alarm
Smoke Detector
Yes
Yes
Yes
High Value Items
Jewelry: $
Silver: $
Furs: $
Fine Arts: $
Cameras: $

Other:

$

Comments or Information


Please click on the "Submit Quote" button to send your quote request.
This is a request for quotation only. No coverage is in effect
until bound by an insurance carrier.


 
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Berger & O'Neal Insurance Group
10425 Old Alabama Road Connector, Suite 101
Alpharetta, Georgia 30022
770-442-0770 Toll Free 1-866-442-0770 Fax 770-442-0774