Richardson & Stout Insurance

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Homeowners Insurance Quote Request

Personal Information

First Name		Spouse First Name
Middle Name		Spouse Middle Name
Last Name		Spouse Last Name
Property Address
City
State
Zip
Home Phone
Work Phone
E-mail Address
How do you prefer we contact you?
Date of Birth
Social Security Number

Property Information

Mailing Address	(if different than your property address)
City
State
Zip
Number of Families
Number of Bedrooms
Number of Full Bathrooms
Number of Half Bathrooms
Number of Fireplaces
Number of Porches or Decks
Square Footage of Porch/Deck
Year House was Built
Purchase Date
Construction Type
How Many Stories?
Foundation Type
Type of Garage
Type of Roof Covering
Last Year Updated
Type of Electrical System
Last Year Updated
Type of Heating System
Last Year Updated
Type of Plumbing
Last Year Updated
Pool
Pool Fenced?
Lockable Fence
Diving Board
Pool Slide
Distance of Fire Protection
Smoke Alarm
Fire Extinguisher
Deadbolts
Automatic Fire Sprinklers
Theft Alarm
Fire Alarm
Monitored Alarms
Fire District
Trampoline
Number of Acres
Dogs on Property
	If yes, how many and what is the breed of each dog?
Other Pets or Animals on Property?
	If yes, how many and what is the description of each?

Current Coverage Information

Losses or Claims in the Last 5 Years?
	If yes, what is the date, amount paid, and description of each loss or claim?

Desired Coverage Information

Dwelling Amount	Coverage A
Other Structures	Coverage B
Personal Property	Coverage C
Loss of Use	Coverage D
Premise Liability	Coverage E
Policy Deductible	Amount
Do you want building replacement cost coverage?
Do you want contents replacement cost coverage?
Comments/Questions

If you have more than one residence, please fill out another form. Please note: Insurance coverage cannot be bound without a written binder from our office. Please also note: Many insurance carriers use information gathered from you and outside sources about your claim, credit history, and home. This information allows insurance companies to determine accurately the proper price to charge. You are entitled to a free copy of the reports by contacting the appropriate consumer reporting agency within the next 60 days. Please view the Legal Disclaimer below to view our privacy policy and how we treat your personal information.