Statewide Insurance Agency
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Homeowner Insurance Quote Form
Step 1 of 11
9%
Enter your ZIP code
*
Is this a new purchase?
Yes
No
How did you hear about Statewide Insurance Agency?
I was referred by another person
Internet search
I received a letter or postcard
Social media or internet ad
Who referred you?
Getting Started
Insurance Type
Homeowners
Condo
Mobile/Manufactured Home
Townhome
Landlord (non-owner occupied)
Renter
Number of household members who are under age 18?
0
1
2
3
4
5
Home Details
Year Home Was Built
Number of Stories
1
1.5
2
Property Type
Single Family Residence
Mobile/Manufactured Home
Condo
Duplex
Townhouse
Occupancy Type
Primary Residence
Secondary Residence
Rental Property
Renter
Exterior Walls
Brick
Stone
Vinyl Siding
Aluminum Siding
Rock
Other
Is there a fire hydrant within 1000 feet of this property
Yes
No
Home Details Continued
Garage Type
Attached
Detached
None
Garage Capacity
1 Car
2 Car
3 Car
4 Car
Basement Type
No basement at all
Less than 50% finished
More than 50% finished
Home Security
No security alarm system
Alarm sounds in home only
Signals to a monitoring alarm system
Roof Type
Asphalt composition (most common)
Wood shake or treated wood slats
Tile or clay shingles (Spanish style)
Metal
Flat
What is the approximate age of your roof surface?
1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years
10 years
11 years
12 years
13 years
14 years
15 years
Greater than 15 years
Have you filed any homeowner insurance claims in the last 5 years?
Yes
No
If yes, please provide us with brief details of what happened and approximately when it occurred.
Home Details Continued
Square Footage
Excluding Basement
Number of Bedrooms
Number of Full Bathrooms
With Shower / Bath Tub
Number of Half Bathrooms
Without Shower / Bath Tub
Number of Fireplaces
Number of Decks
Potential Discounts
Deadbolts
Smoke Alarms
Fire Extinguishers
Manned Fire Station within 5 miles
55 & Retired
House Add-Ons
Add-ons
Central Air Conditioning
Sauna
Hot Tub
Wood Burning Stove
Sump Pump
In-Ground Swimming Pool
Swimming Pool is Fenced
Trampoline
Do You Own Any Dogs?
no
yes
Briefly describe the breed of your dog(s)
Current Policy Information
Do you currently have home insurance coverage?
Yes
No
Current Insurance Carrier
When does your existing policy expire?
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Estimated Market Value
Current Insurance Dwelling Coverage
Coverage Needs
Deductible
1,000
2,500
5,000
1% of Dwelling Coverage
Liability Protection
100,000
300,000
500,000
Additional Needs
Auto Insurance
Extra Jewelry Coverage
Motorcycle
Trailer
Boat
All Terrain Vehicle
Personal Umbrella Liability Insurance
Other
Other
Possible Occupation and Education Discounts
Please provide us with a brief description of your occupation as well as the occupation of any co-applicant (if applicable)?
Highest Education You Have Completed?
high school
some college
college degree
advanced degree
Highest Education of the co-applicant (if applicable)?
high school
some college
college degree
advanced degree
Getting Your Quote
Full Legal Name
First
Middle
Last
Suffix
Date of Birth
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Spouse or Co-Applicants Legal Name (if applicable)
First
Middle
Last
Suffix
Spouse or Co-Applicants Date of Birth
Month
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2008
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1928
1927
1926
1925
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1923
1922
1921
1920
Physical Address Of Property To Be Insured
Street Address
Apt/Suite/Bldg
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Your Current Mailing Address (If different than the physical address of the property to be insured)
Street Address
Apt/Suite/Bldg
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Tell us how and when to contact you
How would you like for us to contact you?
Telephone Only
Email Only
Telephone and/or Email
When would you like for us to contact you?
Please rush it!
As soon as you have it ready (usually one half day)
Request another time
When would be a good time for us to contact you?
Your Contact Info
Primary Phone
Secondary Phone (Optional)
Email Address
Comments/Additional Information
