Homeowner Insurance Quote FormStep 1 of 119%Enter your ZIP code*Is this a new purchase? Yes NoHow did you hear about Statewide Insurance Agency? I was referred by another person Internet search I saw a television commercial Social media or internet adWho referred you?Do you have an agent you prefer to work with?Any available agentDebbie PybasNicholas YllaPreston LeeTrevon NixVon NixGetting StartedInsurance Type Homeowners Condo Mobile/Manufactured Home Townhome Landlord (non-owner occupied) RenterNumber of household members who are under age 18?012345Home DetailsYear Home Was BuiltNumber of Stories11.52Property TypeSingle Family ResidenceMobile/Manufactured HomeCondoDuplexTownhouseOccupancy TypePrimary ResidenceSecondary ResidenceRental PropertyRenterExterior WallsBrickStoneVinyl SidingAluminum SidingRockOtherIs there a fire hydrant within 1000 feet of this property Yes NoHome Details ContinuedGarage TypeAttachedDetachedNoneGarage Capacity1 Car2 Car3 Car4 CarBasement TypeNo basement at allLess than 50% finishedMore than 50% finishedHome SecurityNo security alarm systemAlarm sounds in home onlySignals to a monitoring alarm systemRoof TypeAsphalt composition (most common)Wood shake or treated wood slatsTile or clay shingles (Spanish style)MetalFlatWhat is the approximate age of your roof surface?1 year2 years3 years4 years5 years6 years7 years8 years9 years10 years11 years12 years13 years14 years15 yearsGreater than 15 yearsHave you filed any homeowner insurance claims in the last 5 years? Yes NoIf yes, please provide us with brief details of what happened and approximately when it occurred.Home Details ContinuedSquare FootageExcluding BasementNumber of BedroomsNumber of Full BathroomsWith Shower / Bath TubNumber of Half BathroomsWithout Shower / Bath TubNumber of FireplacesNumber of DecksPotential Discounts Deadbolts Smoke Alarms Fire Extinguishers Manned Fire Station within 5 miles 55 & RetiredHouse Add-OnsAdd-ons Central Air Conditioning Sauna Hot Tub Wood Burning Stove Sump Pump In-Ground Swimming Pool Swimming Pool is Fenced Trampoline Detached Structure CoverageDo You Own Any Dogs? no yesBriefly describe the breed of your dog(s)Current Policy InformationDo you currently have home insurance coverage? Yes NoCurrent Insurance CarrierWhen does your existing policy expire?MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Estimated Market ValueCurrent Insurance Dwelling CoverageCoverage NeedsDeductible 1,000 2,500 5,000 1% of Dwelling CoverageLiability Protection 100,000 300,000 500,000Additional Needs Auto Insurance Extra Jewelry Coverage Motorcycle Trailer Boat All Terrain Vehicle Personal Umbrella Liability Insurance OtherOtherPossible Occupation and Education DiscountsPlease 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 schoolsome collegecollege degreeadvanced degreeHighest Education of the co-applicant (if applicable)?high schoolsome collegecollege degreeadvanced degreeGetting Your QuoteFull Legal Name First Middle Last Suffix Date of BirthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Spouse or Co-Applicants Legal Name (if applicable) First Middle Last Suffix Spouse or Co-Applicants Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Physical Address Of Property To Be Insured* Street Address Apt/Suite/Bldg City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Tell us how and when to contact youHow would you like for us to contact you? Telephone Only Email Only Telephone and/or EmailWhen would you like for us to contact you? Please rush it! As soon as you have it ready (usually one half day) Request another timeWhen would be a good time for us to contact you?Your Contact InfoPrimary PhoneSecondary Phone (Optional)Email Address* Comments/Additional InformationSMS Text Messages Check this box if you would like to receive text messages about your quote (no other marketing text will be sent)
