Collins Insurance Agency, Inc.

Homeowners Insurance Quote

Please note that this form is for a REQUEST ONLY. By submitting this form it does not bind coverage in any way. If you do not hear from us in a reasonable amount of time, ASSUME WE DID NOT GET THIS REQUEST FOR AN INSURANCE QUOTE, and call our office.

I understand that filling out and submitting this form DOES NOT bind coverage in any way, and the only way coverage can be bound will be when I am informed of a binder or policy is issued by the agent representing me.

General Info
Name:
Address:
City:
State:
Zip Code:
Home Phone:
Cell Phone:
Email Address:
Best Time To Contact:
Contact By:

Current Policy Information
Company:
Years With Company:
Policy Expiration Date:

Dwelling Information
Year Built:
Construction:	If "Other", specify
Number of Stories:
Square Feet:
Additional Info:
Is this Secondary or Main Residence?:
Property Occupied By:
Type of Roof:	If "Other", specify
Roof Covering:	If "Other", specify
Garage:
Attached Porches/Carports:
Foundation Type:
Amount of Insurance Requested on Dwelling:	$ (Replacement Cos, not Market Value)
Distance from Water or Coastal Exposure:
Distance to Fire Hydrant (in feet):
City Limits:
Business Pursuits on Property

Utilities Updated in the last 20 Years: If you select yes to any of the utilities updated, please specify the year of the update in the respective box provided.
Heating	Year Updated:
Wiring:	Year Updated:
Roof:	Year Updated:
Plumbing:	Year Updated:
Full Circuit Breakers:	Year Updated:

Amenities
Number of Bathrooms
Basement:
Deck:
Porch:
Patio:
Size of (in sq. ft) Screened Enclosures:	sq. ft
Size of (in sq. ft) Pool Enclosures:	sq. ft
Number Of Fireplaces:
Central Station Alarm:
Central Station Fire Alarm:
Hurricane Shutters:
Central Air:

Additional Questions
Do you have any animals?:
Do you have a trampoline?:
Have you cancelled, declined or non-renewed?::	If yes, please explain
Number Occupants:
Do you have a swimming pool?:	If yes, screened or fenced: If yes, diving board or slide:
Does any household member smoke any tobacco product?:
Do you have any supplemental heating?:	If yes, please explain

Additional Information In the box below, please provide any additional information you feel may be necessary for us to provide you with the best quote possible such as additional operators, coverages engines, etc.