HOMEOWNERS INSURANCE FORM

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Please use the below quote forms or call us TOLL FREE direct at 877-901-5544.

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Personal Information
Who is Insured?	Last
	First
	Middle
Return Call Phone Number
What is your email address?	Email
What is your date of birth (for discount purposes)?	Date of Birth
How would you rate your credit?	Credit
Property Information
What is the property address?	Street
	City
	State
	Zip
What is your home insured for now?
What is your home worth today?	Current Worth of Home
Number of families?	#Families
What is the dwelling type?	Dwelling Type
About what year was it built?	Year Built
What year was the property purchased?	Purchased
What is the construction type?	Construction Type
How many stories?	Stories
Does the building have a pool?	Pool	Yes No
Is the electrical updated?	Electrical Update
Are there circuit breakers?	Circuit Breakers	Yes No
Is the heating/ air conditioning thermostatically controlled?	Thermostatically Controlled	Yes No
Do you have a trampoline?	Trampoline	Yes No
Number of acres dwelling is located on	Number of acres
Are there dogs on the property?	Dogs on Property	Yes No
If yes, how many and what is the breed of each dog?
Are there any other pets or animals on the property?	Pets or Animals	Yes No
If yes, how many and what is the description of each?
Is your home inside the city limits?	Inside City Limits	Yes No
Is there a vacant dwelling next to your home??	Vacant Dwelling Next to Home	Yes No - If yes, explain at bottom of page.
Is your home currently in need of or under any repair or renovation?	In Need of Repairs	Yes No - If yes, explain at bottom of page.
Are there handrails on all steps exceeding two steps?	Handrails	Yes No
General Condition of Home	Condition of Home	Excellent Good Fair Poor
Who is paying the first year premium?	Who is Paying Premium	Insured Mortgagee
Mode of payment	Mode of Payment	Monthly Quarterly Semi-Annual Annual
Current Coverage Information
What is the current insurance company?
What is the expiration date of current policy?	Expiration Date	.
Where there any losses or claims in the last 5 years?	Losses - Claims	Yes No
If yes, what is the date, amount paid and description of each loss or claim?
Desired Coverage Information
Dwelling Amount	Coverage A
Other Structures	Coverage B
Personal Property	Coverage C
Premise Liability	Coverage E
Policy Deductible	Amount
Do you want actual cash policy or a policy to rebuild new?		Cash Policy Policy to Rebuild New
Do you want contents replacement cost coverage?		Yes No
Questions or Comments	NOTICE: Some companies use an insurance score. This can often improve your rate. If you would like us to use this underwriting tool please provide us your social security number in the remarks box below. (Rules of the Fair Reporting Credit Act and Federal Consumer Credit Protection Law, will apply)
If you have more than 1 residence, please fill out another form Insurance coverage will not be canceled, bound or modified without a written comfirmation from Ledbetter Insurance Agency. Please Also Note: Many insurance carriers use information gathered from you and outside sources about your claim, credit history and home. This information allows insurance companies to determine accurately the proper price to charge. You are entitled to a free copy of the reports by contacting the appropriate consumer reporting agency within the next 60 days. By filling out this form, you agree to the above terms.

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