MyPolicy.com - Homeowner's Insurance Quote Form

Section One - Personal Information

Name:

Address:

City:

State:

Zip:

Country:

Telephone:

Fax:

E-Mail:

Date of Birth

Are you currently a Fitts Insurance customer? Yes No

Section Two - Home Description

Construction Type: Brick Frame

Year Built:

If the home is more than 20 years old, please advise the date that the following items were updated:

Plumbing:

Heating:

Electrical:

Roof:

Living Space Area: square feet

Style of House:

Number of Families:

Please select all that apply to your home:

Local smoke detectorLocal burglar alarm

Centrally monitored fire alarmCentrally monitored burglar alarm

Deadbolt locksFire extinguisher

Water leak alarm

Is your home within three (3) miles from a fire station? Yes No

Is your home within 500 feet from a fire hydrant? Yes No

Do you want replacement cost coverage on your home's contents? Yes No

Are you a non-smoker? Yes No

If you own automobiles, would you be interested in combining the autos with the homeowner's policy for additional discounts? Yes No

How many automobiles do you own?

Which company insures them?

What liability limit do you have?

Section Three - Coverage Limits

Dwelling:$

Contents:$

Liability:$

Deductible:$

Select any additional coverage options:

Water backupEarthquake

Identity theft expensesOrdinance/law coverage

Fungi, wet/dry rot, bacteria increased limits

List any items which you desire to have scheduled for an agreed amount, i.e. jewelry, furs, silverware:

Section Four - Claims History

How many years have you owned your home?

How many years have you been loss free?

Please describe all claims that you have incurred in the last ten (10) years:

Section Five - General Information

Have you had any homeowner claims or losses within the last six (6) years? If so, please explain:

Do you own any recreational vehicles such as boats, snowmobiles, golf carts, ATV's, motor homes,, etc? Yes No

Do you own any additional residences? Yes No

Do you have a wood stove? Yes No

Do you have a swimming pool? Yes No

If so, is the pool completely within a fence enclosure? Yes No

Does the pool have a slide? Yes No

Does the pool have a diving board? Yes No

Current policy expiration date:

Please list all animals owned:

Would you like a quote for an umbrella liability policy? Yes No

Limit desired:$

Do you conduct any business in the home? Yes No

If yes, do customers or vendors visit the home? Yes No

Do you require water back-up coverage? Yes No

Please indicate how you found our web site:

Prior Fitts Insurance Customer
Referral/Word of mouth

Please tell us who referred you:

Newspaper advertisement
Internet banner advertisement
Radio advertisement
Yellow Pages
Internet Search Engine

Google
Yahoo
Altavista
Webcrawler
Lycos
Other :

Other

Any additional comments: