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CONTACT INFORMATION:


















UNDERWRITING INFORMATION:



















































COVERAGE INFORMATION:






































Thanks for letting us quote your home insurance. May we also give you a quote for

HOMEOWNERS INSURANCE QUOTE REQUEST
By completing and submitting this form I have reviewed the privacy statement of the Harnist Insurance Agency and understand its content and hereby grant permission to utilize the information I provide to secure insurance proposals on my behalf.

Please note that providing as much information as possible will ensure accurate pricing. Any indication of rates are subject to underwriting, verification of information, and acceptance by the insuring company.

If you have just submitted a quote form, please check box, fill in your first and last name, and skip to underwriting information.
First Name:



Spouse's name

Date of birth:



Spouse's date of Birth:
Last Name:
Address:
City:
State:
Zip Code:
E-Mail Address:

Add me to your e-mail list
Day Phone:
Evening Phone:
Contact Preference:
Years at current address:

If at current residence less than 6 months, please provide previous address in remarks below.





# OF STORIES

Total square feet of
living space in your home? (Excluding finished basement area)
CONSTRUCTION Garage - number of cars
Check if garage is detached from home.
FOUNDATION
What percent of basement is finished?

Number of bathrooms in your home.

# of 1/2 baths:
# of full baths:
# of custom baths:
ROOF


Please indicate if you have any attached structures:

Hold down your control key to make multiple selections.

Please provide approximate square footage of each in the space below.

Please check all that apply:
Do you belong to a homeowner's association?YesNo
Is your home in a trust?
YesNo
Do you own ANY motorized vehicle not licensed for road use?
YesNo
Do you own a boat or jet ski?
YesNo
Do you run a business in your home?
YesNo
Please gives details of any YES item in remarks at the bottom of this form.


CENTRAL ALARM

HEATING


# of fireplaces:


Check here if you have a woodburning stove or furnace in your home.
PETS

Breed or description:

OTHER PROTECTION
Check all that apply:
Smoke Alarms

Deadbolt locks

Fire Extinquishers
GENERAL INFO.
Year home was built

Swimming Pool Fenced?YesNo
Trampoline?YesNo
UTILITIES
Central Air?
If home is over 30 years old, what year was last update? If no update, type NONE.
Electrical-year

Heating-year

Plumbing-year

LOSS HISTORY
Have you had any homeowner losses in the past 5 years? If yes, provide dates, amount, and details in comments below.




POLICY




Present company
(not agent)



Renewal or Closing date
Deductible

Is current policy being canceled or non-renewed?
If yes, give reason in comments below.


Auto ins. same co. as home?
COVERAGE LIMITS
Dwelling
(type NONE if renting)


Contents


Personal Liability


Medical payments

(NOTE: other structures & loss of use coverage will be included as a percentage of dwelling limit)
OPTIONAL COVERAGES
Earthquake
Mine subsidence
Sewer Backup
Scheduled property
Hold down the control key to make multiple selections.

Personal umbrella liability

COMMENTS
Please provide any additional information you feel necessary for us to assess your insurance needs.


If you have interest in other forms of insurance, please check all that apply.
Life
Health
Disability
Long Term Care
Boat / Jet Ski
Flood Ins.
Investment properties
Recreational vehicles

This form will be sent directly to our agency in the form of an e-mail. The information you have provided will only be used for the purposes of securing a proposal of insurance. A licensed insurance agent will consult with you to determine the best plan of insurance to meet your needs. No coverage is implied and there is no obligation to you, our agency, or the companies we represent. Thank you for your interest in our services.