Choice Insurance Agency
Home Quote Sheet
Name:
Referred by:
Date:
Street:
City:
Zip:
Home Phone:
Work:
Cell:
Occupation: (H)
(W)
Construction:
Frame
Brick
Siding
Year Built:
Year of Last Update: Roof:
Electrical:
Plumbing:
Heat:
# of Stories:
One
Two
Three
Square Feet:
Basement:
Yes
No
Percent Finished:
Slab
Crawl
Garage:
Attached
Detached
No. of Cars:
1 Car
2 Cars
3 Cars
4 Cars
Bathrooms: Full
Half
Central Air?
Yes
No
Fireplace:
Yes
No
How Many?
Wood Stove?
Yes
No
Swimming Pool:
Inground
Above Ground
Fenced
Dving Board
Slide
Wood Deck:
Yes
No
Square Feet:
Trampoline:
Yes
No
Screened Porch:
Yes
No
Square Feet:
Central Station Alarm System:
Yes
No
Dead Bolts:
Yes
No
Smoke Detectors:
Yes
No
Fire Extinguisher:
Yes
No
Any Smokers in Household?
Yes
No
Any Pets?
Claims in last 3 Years:
Current Market Value/Price Paid:
Home is currently insured at/or mortgage amount:
Current Carrier:
Ex-Date:
Proposed Closing Date or Renewal Date:
E-mail Address: