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Request a Quote

Request a quote for your home and/or auto insurance.

Your form will be returned to our office by secure email.

Homeowner’s Quote Form

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 provided to secure insurance proposals on my behalf.

Any indication of rates are subject to underwriting, verification of information, and acceptance by the carrier.

This form is transmitted to our office by secure encrypted email.

Please note: The more accurate the information you provide, the more accurate the quote we present

Full Name:*

Date of Birth:

Spouse's Full Name:

Spouse's Date of Birth:

*Street Address:*

City:

State*

ILMO

Zip:*

Email Address:

Day Phone:

Evening Phone:

Contact Preference:

Years at Current Address:

If at current residence less than six months, please provide previous address:

Number of Stories:

Square Footage:

Construction:

Attached Garage:

YesNo

Garage - Number of Cars:

Foundation:

What percent of basement is finished?

Number of 1/2 bathrooms:

Number of full bathrooms:

Type of Roof:

Age of Roof:

Please indicate if you have any attached structure:

DeckOpen PorchEnclosed PorchSunroomDeck with Sauna

Please provide square footage of each attached structure:

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 give details of any YES item in remarks:

Central Alarm:

Other Protection (check all that apply):

Smoke AlarmsDeadbolt locksFire Extinguishers

Heating:

Number of fireplaces:

Do you have a woodburning stove or furnace in your home?

YesNo

Pets:

DogCatOther

Breed or description:

Year home was built:

Swimming Pool?

Trampoline?

YesNo

Do you have a fenced in backyard?

YesNo

Do you have central air?

YesNo

Electrical-update year:

Heating-update year:

Plumbing-update year:

Have you had any homeowner losses in the past 5 years?

YesNo

If yes, provide dates, amount, and details:

Current policy company:

Renewal or Closing Date:

Deductible:

Is current policy being canceled or non-renewed?

YesNo

If yes, give reason:

Do you have auto insurance through the same company as home?

YesNo

Current Coverage Dwelling:

Current Coverage Contents:

Current Coverage Personal Liability:

Current Coverage Medical Payments:

Optional Coverages - Earthquake:

YesNo

Optional Coverages - Mine Subsidence:

YesNo

Optional Coverage - Sewer Backup:

Optional Coverage - Scheduled Property:

JewelrySilverGunsHearing AidOther

Personal Umbrella Liability:

Please provide any additional information:

If you have interest in other forms of insurance, please check all that apply:

AutoHealthDisabilityLong Term CareBoat/Jet SkiFloodInvestment PropertiesRecreational VehiclesLife

Email submit disclaimer*

I understand this form will be transmitted by secure encrypted email to Harnist Insurance for review

A licensed insurance agent will consult with you to gather any additional information needed and 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.

Automobile Quote Form

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 provided to secure insurance proposals on my behalf.

Any indication of rates are subject to underwriting, verification of information, and acceptance by the carrier.

This form is transmitted to our office by secure encrypted email.

Please note: The more accurate the information you provide, the more accurate the quote we present

Full Name:*

*Street Address:*

City:

State*

ILMO

Zip:*

Email Address:

Day Phone:

Evening Phone:

Contact Preference:

Years at Current Address:

If less than six months, give full previous address:

Do you presently have insurance coverage?

YesNo

If yes, what is the name of the company?

Are you being canceled or non-renewed by your present company?*

YesNo

Vehicle 1 - Year, Make & Model*:

Vehicle 1 - Vehicle Identification Number (VIN):

Vehicle 1 - Usage*:

Vehicle 2 - Year, Make & Model:

Vehicle 2 - Vehicle Identification Number (VIN):

Vehicle 2 Usage:

Vehicle 3 - Year, Make & Model:

Vehicle 3 - Vehicle Identification Number (VIN):

Vehicle 3 Usage:

Vehicle 4 - Year, Make & Model:

Vehicle 4 - Vehicle Identification Number (VIN):

Vehicle 4 Usage:

Any Vehicle Custom Add on Equipment - desribe in addl info field below:

YesNo

If yes, please describe and give value:

Driver 1 - Full Name:

Driver 1 - License Number:

Driver 1 - Sex:

MaleFemale

Driver 1 - Date of Birth:

Driver 1 - Years Licensed:

Driver 1 - Full time student:

YesNo

Driver 1 - Away at school:

Driver 1 - Good Student B Average?:

YesNo

Driver 1 - Marital Status:

Accidents or Losses last five years:

YesNo

Ticket last five years:

YesNo

Details including dates, tickets, accidents, or other loss:

Driver 2 - Full Name:

Driver 2 - License Number:

Driver 2 - Sex:

MaleFemale

Driver 2 - Date of Birth:

Driver 2 - Years Licensed:

Driver 2 - Full time student:

YesNo

Driver 2 - Away at school:

Driver 2 - Good Student B Average?:

YesNo

Driver 2 - Marital Status:

Accidents or Losses last five years:

YesNo

Ticket last five years:

YesNo

Details including dates, tickets, accidents, or other loss:

Driver 3 - Full Name:

Driver 3 - License Number:

Driver 3 - Sex:

MaleFemale

Driver 3 - Date of Birth:

Driver 3 - Years Licensed:

Driver 3 - Full time student:

YesNo

Driver 3 - Away at school:

Driver 3 - Good Student B Average?:

YesNo

Driver 3 - Marital Status:

Accidents or Losses last five years:

YesNo

Ticket last five years:

YesNo

Details including dates, tickets, accidents, or other loss:

Driver 4 - Full Name:

Driver 4 - License Number:

Driver 4 - Sex:

MaleFemale

Driver 4 - Date of Birth:

Driver 4 - Years Licensed:

Driver 4 - Full time student:

YesNo

Driver 4 - Away at school:

Driver 4 - Good Student B Average?:

YesNo

Driver 4 - Marital Status:

Accidents or Losses last five years:

YesNo

Ticket last five years:

YesNo

Details including dates, tickets, accidents, or other loss:

Bodily injury limit - all vehicles (,000's)*:

Property damage limit - all vehicles (,000's)*:

Medical payment limit - all vehicles (,000's)*:

Uninsured/Underinsured Motorist - all vehicles (,000's)*:

Comprehensive deductible:

Which vehicle - check all that apply:

All vehiclesVehicle 1Vehicle 2Vehicle 3Vehicle 4

Collision deductible:

Which vehicle - check all that apply:

All vehiclesVehicle 1Vehicle 2Vehicle 3Vehicle 4

Towing - check all that apply:

All vehiclesVehicle 1Vehicle 2Vehicle 3Vehicle 4

Car Rental:

YesNo

Please provide any additional information here:

If you have interest in other forms of insurance, please check all that apply:

HomeLifeHealthDisabilityLong Term CareBoat/Jet SkiFloodInvestment propertyRecreational vehicles

Email submit disclaimer*

I understand this form will be transmitted by secure encrypted email to Harnist Insurance for review

A licensed insurance agent will consult with you to gather any additional information needed and 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.

Rates provided are subject to company underwriting, verification of information provided, and acceptance by the insuring company. The information provided for home and auto quotes will be forwarded to our agency in the form of email and shall only be used for the purpose of providing an insurance proposal for your consideration. A licensed agent will be in contact with you to best determine your needs. Submission of these forms shall not imply any coverage and there is no obligation to you, our agency, or the insurance companies we represent.

If you have any questions or concerns regarding a loss, please do not hesitate to call our office.