Tuesday, September 07, 2010    

Homeowner Quote – Required Info

Please fill out the information below that will be emailed to KMA for review and contact. Requested quote info will be submitted for review and someone from KMA will be in touch within the next 2 business days to discuss options.

Name:
Address:
Date of Birth:
Social Security #:
Phone #:
Closing Date (Only if new purchase):
Type of insurance:

Homeowner     Condo    Renters

Year Built:

Construction:

 Frame   Brick
Stories/Style

Bath’s #:
 
Updates:
  

Roof:

Furnace:

Electrical:
Plumbing:
 
Electrical 100AMPS – All Breakers: 
Yes No

Animals:

 Yes No
Type & Breed

Central Air:

 Yes No
Fireplace:
 Yes No

      Masonry or Prefabricated
Basement:

Basement Crawlspace Slab

     If Basement - % Finished:
Pool:
 Yes No

   If Yes: Depth:  Gated:  Slide/DB:

Trampoline:

 Yes No

Garage Type:
 

Coverages:

  

Current Carrier:

Dwelling:

Other Structures:
Personal Property:
Loss of Use:
Personal Liability:
Medical Payments:
Deductible:

Scheduled jewlery:

   
Sump Pump:
Yes No
Earthquake:
 Yes No

Claims last 3 years:
 

Other coverages or miscellaneous endorsements:
 
 Office Hours: Monday - Friday 8:30 am - 5:00 pm      Phone: 815.633.8765  Fax: 815.633.8799
©2010 Ken McEachran Agency, Ltd.