Home Owners Insurance Quote Jacksonville

Personal Information

*Full Name:
*Address to be Insured:
*City:
*State:
*Zip Code:
*Email Address:
*Home Phone:
Work Phone:
Ext.

How to Contact You: Select One Phone at Work Phone at Home
*Date of Birth:
(mm/dd/yyyy)

Do you currently have homeowner insurance? Select One Yes No
Current Insurance Company:
Policy Expiration Date:
(mm/dd/yyyy)
Current Premium: $
per year
Coverage requested for: Select One House Condominium Apartment Townhouse Farm House Other
Usage Type: Select One Primary Home Seasonal Farm Second Home Vacant Other
Years Lived at Address to be Insured: Select One Less than 1 1 to 2 years 2 to 5 years Over 5 years Haven't moved in

Policy Endorsements Requested

Dwelling ($ coverage limit):
Additional Structures ($ value):
Personal Property ($ value):
Personal Liability (each occurence): Select One $100,000 $300,000 $500,000
Medical Payments (each person): Select One $1,000 $2,000 $5,000
Deductible: Select One $250 $500 $1,000 $2,500
Hurricane Deductible: Select One 2% 5% 10%
Do you need Flood Insurance: Select One Yes No

Florida Homeowner Insurance - Dwelling Information

Building Structure: Select One Frame Masonry Masonry Veneer
Year Dwelling Built:
Dwelling Square Feet:
Primary Heat Type:
Select One Central Floor Furnace Wood Stove
Fireplace: Select One Yes No
Garage: Select One Attached Unattached None
Garage Size: Select One 1 car 2 car 3 car 4 car
Alarm System: Select One Yes No
Gated Community: Select One Yes No
Hurricane Shutters: Select One Yes No
Wiring Renovation: Select One Partial Complete
Wiring Renovation Year:
Plumbing Renovation: Select One Partial Complete
Plumbing Renovation Year:
Heating Renovation: Select One Partial Complete
Heating Renovation Year:
Roofing Renovation: Select One Partial Complete
Roofing Renovation Year:
Roof Type: Select One Composition Wood Cement
Roof Age (years):
Dwelling Occupied By: Select One Owner Tenant Other
Swimming Pool: Select One Above Ground In-Ground None
Diving Board: Select One Yes No
Trampoline: Select One Yes No
Any Pets: Select One Yes No
If you answered "Yes", please list type of pet.
Approved Fence: Select One Yes No

Loss History

Did you have any losses, whether or not paid by insurance, during the last 3 years, at this dwelling location or any other location? Select One Yes No

If the answer to the previous question was "Yes", please explain below.

Date:
Type:
Description of Loss:
Amount of Loss:

Additional Information or Comments