Locally Owned and Operated by Fausto Bucheli, Jr.
 
1-877-203-4572 CA License 0A94432
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Homeowners Quote Request Form

* = Required Fields

Homeowner/Contact Information
* Todays Date:
(mm/dd/yyyy)
* Owner's First Name:
* Owner's Last Name:
* Street Address:
* City:
* State:
* Zip:
* County:
* Valid Email Address:
* Home Phone:
(999-999-9999)
* Work Phone:
(999-999-9999)
* Owner's Date of Birth:
(mm/dd/yyyy)
* Owner's Gender:
Owner's Social Security Number:
(e.g. 555-55-5555l)
* How would you (owner) describe your credit rating?:
Poor
Good
Excellent
Unsure
* Current Residence Status:
* Length of time at current residence?:

* Best time to contact you?:

* Best way to contact you?:

Email Phone
Work Phone

* How quickly do you need your request processed?:
Please provide any comments you have:
Are you interested in a multiple-policy discount (for auto and home insurance)?:
 Yes No
* Are you currently (or have you ever been) a Brooke customer?
Yes No
* How did you hear about Brooke?
Insurance Information
Please tell us more about your current or recent insurance policy. Be as accurate as possible.
* Your most current insurance company:
* What date does your current policy expire/renew?
(mm/dd/yyyy)
* How long have you been insured with your current insurance company?:
* How long have you been continuously insured with this company?
Property Location and Type
* Address of the property to be quoted:
Address 2 or Apt. Number:
* City/Township:
* County/Parish:
* State:
* Zip Code:
* Please select the property type:
* Do you currently own (or are you in the process of purchasing) this property?:
Yes No
* Do you now reside, or plan on residing at this property within the next 12 months?:
 Yes No
Property Coverage Information
* How much Residence coverage do you want?:
(In dollars, for example: 250,000)
* How much personal liability coverage do you want?:
* How much deductible?:
(The higher your deductible, the lower your premiums)
* Approximate year property built:
* Approximate livable square footage of residence:
(excluding basement, if any)
* Is this your primary or secondary residence?:
* Is business or farming conducted on this property?:
Yes No
* Do you have any of the following breeds of dogs: Chow, Doberman, German Shepherd, Pit Bull, Rottweiler, Wolf Hybrid, or mix of these?:
 Yes No
* Dwelling design:
* Exterior wall type:
(60% or more)
* Number of Bedrooms:
* Number of Bathrooms :
* Roof Type:
* Roof Age:
* Garage Type:
* Describe Foundation or Basement:
* Wiring Type:
* Service Panel Type:
* Central Burglar Alarm:
* Central Fire Alarm:
* Fire Station:
* Fire Hydrant:
* Municipal Location:
* Please describe the heating system in this dwelling:
* Number of gas, pellet or wood fireplaces or stoves:
* Is your home prone to flooding or located in a designated flood plain?:
* Property Accessories
Dead Bolts Air Conditioning Tennis Court
Smoke Detectors Covered Deck/Patio Trampoline
Fire Extinguisher Uncovered Deck/Patio  
Indoor Fire Sprinkler Swimming Pool  
Claims Information
Claim Type:
Date of Claim:
(mm/dd/yyyy)
Claim Type:
Date of Claim:
(mm/dd/yyyy)
Claim Type:
Date of Claim:
(mm/dd/yyyy)