Homeowners Quote Request Form

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* = Required Fields

Homeowner/Contact Information
* Todays Date: (mm/dd/yyyy)
* Owner's First Name:		* Owner's Last Name:
* Street Address:		* City:
* State:	AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY	* 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:	Male Female
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:	Own Rent Live With Parents Dormitory Choice Not Listed	* Length of time at current residence?:
* Best time to contact you?: * Best way to contact you?:	Anytime Morning Afternoon Evening Email Phone Work Phone	* How quickly do you need your request processed?:	ASAP 1 Day 2 Days 3 Days 4 Days 5 Days 6 Days 1 Week
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:	AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY	* Zip Code:
* Please select the property type:	Single Family Home Multi Family Home Apartment Duplex Condominium Townhome Mobile Home Other	* 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?:	100,000 300,000 500,000 1,000,000
* How much deductible?: (The higher your deductible, the lower your premiums)	100 250 500 1000 2000	* Approximate year property built:
* Approximate livable square footage of residence: (excluding basement, if any)		* Is this your primary or secondary residence?:	Primary Secondary
* 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:	One Story Bi Level Two Story Tri Level Other	* Exterior wall type: (60% or more)	Aluminum or Vinyl Siding Mostly Brick Mostly Wood Frame Stucco Cinder Block Mostly Stone Veneer Log Other
* Number of Bedrooms:	1 2 3 4 5 6 7+	* Number of Bathrooms :	1 1.5 2 2.5 3 3.5 4+
* Roof Type:	Composition Shingle Tile Wood Shingle Concrete Other	* Roof Age:	1-5 years 6-10 years 11+ years
* Garage Type:	Attached - 1 Car Attached - 2 Car Attached - 3 Car Attached - Carport Detached - 1 Car Detached - 2 Car Detached - 3 Car Detached - Carport No Garage Other	* Describe Foundation or Basement:	Bsmt Fully Finished Bsmt 3/4 Finished Bsmt 1/2 Finished Bsmt 1/4 Finished Bsmt Unfinished Crawl Space Piers Pilings Stilts Slab Other
* Wiring Type:	Copper Aluminum Knob and Tube Unknown	* Service Panel Type:	Circuit Breaker Fuse Box Unknown Other
* Central Burglar Alarm:	None Monitored Unmonitored	* Central Fire Alarm:	None Monitored Unmonitored
* Fire Station:	Within 5 Miles Within 10 Miles Over 10 Miles	* Fire Hydrant:	Within 1000 Feet Over 1000 Feet
* Municipal Location:	Inside City Limits Outside City Limits	* Please describe the heating system in this dwelling:	Gas (Forced Air) Electric Boiler Oil/Coal/Kerosene Propane Stove Unknown Other
* Number of gas, pellet or wood fireplaces or stoves:	0 1 2 3 4 5	* Is your home prone to flooding or located in a designated flood plain?:	Not Applicable Designated Flood Plain Prone to Flooding
* 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:	Fire or Lightning Damage Windstorm or Hail Damage Ice Snow Sleet Damage Smoke Damage Water Damage Vandalism Theft Loss Claim Not Listed	Date of Claim: (mm/dd/yyyy)
Claim Type:	Fire or Lightning Damage Windstorm or Hail Damage Ice Snow Sleet Damage Smoke Damage Water Damage Vandalism Theft Loss Claim Not Listed	Date of Claim: (mm/dd/yyyy)
Claim Type:	Fire or Lightning Damage Windstorm or Hail Damage Ice Snow Sleet Damage Smoke Damage Water Damage Vandalism Theft Loss Claim Not Listed	Date of Claim: (mm/dd/yyyy)