Homeowners Insurance
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HOMEOWNERS INSURANCE QUOTE REQUEST
Complete the following information if you would like to obtain a quote on Homeowners Insurance. Please understand this is not an application for insurance. An application will be sent to you if coverage is desired.
All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
The home may be a single family owner occupied dwelling (home), condo or townhome. This program may provide dwelling fire coverage, contents - personal property, loss of use, separate structures such as a detached garage or shed, premise medical and premise liability insurance.
Complete this form to get a quote on a single family owner occupied home, condo or townhouse.
You can also get a quote on:
Rental Property (1-4 units)
Mobilehome
Apartment Building (5+units)
Personal Information
What is your name?
Last
First
Middle
What is your mailing address?
Street
City
State
Zip
What is your telephone number?
Home
Work
What is your fax number?
Fax
What is your email address?
Email
Property Information
What is the property address?
Street
City
State
Zip
What is the dwelling type?
Dwelling Type
How many bedrooms are there?
Number of Bedrooms
How many bathrooms are there?
Number of Bathrooms
How many fireplaces are there?
Number of Fireplaces
How many porches or decks are there?
Porches or Decks
What year was it built?
Year Built
What date was the property purchased?
Purchase Date
What is the construction type?
Construction Type
How many stories?
Stories
If two stories, what is the ground floor square footage?
Ground Floor Square Footage
What is the total square footage of the building?
Total Square Footage
What is the property's topography?
Property's Topography
What foundation type?
If structure is located in a flood zone, what is the distance to body of water?
What type of garage?
What type roof covering?
Was the roof updated?
Updated Roof
Yes No
If yes, what year?
Year Roof Updated
Does the building have a pool?
Pool
Yes No
If there is a pool, is it fenced?
Pool Fence
Yes No
If there is a pool, is there a diving board?
Pool Diving Board
Yes No
If there is a pool, is there a slide?
Pool Slide
Yes No

What is the distance of fire protection?


Is the building in the brush?
Brush
Yes No
Is there a brush hazard within one mile of the building?
Brush Within 1 Mile
Yes No
If yes, has the brush been cleared by 250 feet from all sides of the building?
Brush Cleared by 250 Feet
Yes No
Is there a smoke alarm?
Smoke Alarm
Yes No
Is there a fire extinguisher?
Fire Extinguisher
Yes No
Are there deadbolts?
Deadbolts
Yes No
Is the electrical updated?
Electrical Update
Are there circuit breakers?
Circuit Breakers
Yes No
Does the electrical circuit box have copper wiring?
Copper Wiring
Yes No
How old is the heating/ air conditioning?
Age Heating/ Air Conditioning
Is the heating/ air conditioning thermostatically controlled?
Thermostatically Controlled
Yes No
What is the energy source?
Energy Source
What is the heating system?
Heating System
What is the cooling system?
Cooling System
Has the plumbing been updated?
Plumbing Updated
Yes No
Is the plumbing copper?
Copper
Yes No
Does the building have interior automatic fire sprinklers?
Automatic Fire Sprinklers
Yes No
Is there a theft alarm?
Theft Alarm
Yes No
Is there a fire alarm?
Fire Alarm
Yes No
What is the earthquake zone?
Earthquake Zone
Has it been earthquake retrofitted?
What is the fire district?
Fire District
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?
Current Coverage Information
What is the current insurance company?
What is the expiration date of current policy?
Expiration Date
.
Were 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
Business Property
Coverage C
Loss of Use
Coverage D
Premise Liability
Coverage E
Policy Deductible
Amount
If earthquake insurance is requested, select deductible percentage %
Earthquake Deductible
Do you want building replacement cost coverage?
Building Replacement Cost Coverage
Yes No
Do you want contents replacement cost coverage?
Contents Replacement Cost Coverage
Yes No
Questions or Comments
Best Time to Contact You
Please let us know the best time to call and discuss your quote.
Morning
Afternoon
Evening
Anytime
Or specify other:
     
 
THE GLOVER AGENCY, LLC

145 E. BROAD STREET | EUFAULA, AL 36027
Phone 334-687-0358 or 888-882-2181
Fax 334-687-2365
 
 
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