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Home Insurance

How Did You Find Us?

1. How Did You Find This Site? Google Yahoo SEVRAR Other (required)
2. If Other, Where?

Your Information

1. Your Name(required)
2. Street Address(required)
3. City, State, & Zip Code(required)
4. E-Mail(valid email required)
5. E-Mail (Again)(valid email required)
6. Phone
7. Fax (Optional)
8. Your Birthdate
9. Marital Status Married Single
10. If Married, Spouse Name
11. Spouse Birthdate

Dwelling Information

1. Is This Manufactured or Mobile Home?
2. No Yes
3. Year Home Built
4. Home Square Footage
5. Number of Units 1 Single Family Home Duplex Tri-Plex 4-Plex
6. Type of Foundation Slab Basement Crawlspace over slab other
7. Type of Construction Frame/stucko Frame/wood Brick Block Other (list in remarks)
8. Type of Roof Shingle Concrete Tile Wood Shake Tar/Gravel Metal Other
9. Number of Stories 1 1.5 2 3 Tri-Level
10. Do You Own Animals Or Pets No Yes
11. If yes, list type (if dog, list what breed too)
12. Are You Near A Brush Area? No Yes
13. Feet to Fire Hydrant 0-500 501-1000 1001-1500 1501-2000 2001+
14. Miles To Nearest Firestation
15. Attached Garage? None 1 car garage 2 car garage 3 car garage 4 car garage 5 or more car garage
16. Attached Carport? None 1 car carport 2 car carport 3 car carport 4+ carport
17. Detached Garage or Carport? (list number of cars and type)
18. Heating Type Electric Gas Oil
19. Number of Bedrooms 1 2 3 4 5 6 7 8 9 10 or more
20. Number of Baths 1 1.5 2 2.5 3 3.5 4 4.5 5 more than 5
21. Number of Fireplaces 1 2 3 4 5 6 more than 6
22. Special Features (deck, alarm, other buildings on property, etc.)

Insurance Information

1. Currently Insured? Yes No
2. If No, is this new purchase? N/A Yes No
3. If Yes, Current Carrier & How Long?
4. Any Claims? (list dates & details)
5. Swimming Pool? No Yes, No Diving Board Yes, With Diving Board Yes, With Diving Board

Coverage Information

1. If you don't know the information below we'll do our best to generate quotes off the info you've submitted.
2. Dwelling Coverage
3. Contents Coverage
4. Liability Coverage 100,000 300,000 500,000
5. Scheduled Property & Amount (Jewelry, Art, etc)list amount insured, type of scheduled property, etc.
6. Deductible 1000 500 250 1500 or more
7. Comments or Remarkslist any other special coverage desired or important information

How Should We Contact You?

1. Send My Quote Via E-Mail Fax Regular Mail Please Call Me!
2. We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes.
3. By answering the box below and clicking the "Quote Me" button you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.
4. What color is snow?

 

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Copyright © 2007-2008 · Fox Insurance Services, LLC · (480) 699-7222 · (877) 855-7222
4824 E. Baseline Rd. Ste. 101, Mesa, AZ 85206

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