Skip to content
Contact Us Today 1.847.640.8000
|
info@midwestga.com
Get A Quote
Get A Bond
Request Consultation
About Us
Health
Employee Benefits
Medicare
Dental and Vision
Business
Home
Auto
Pet
Blog
Contact Us
Request a Consultation
Find An Agent
About Us
Health
Employee Benefits
Medicare
Dental and Vision
Business
Home
Auto
Pet
Blog
Contact Us
Request a Consultation
Find An Agent
Homeowners Quote
Adrian
2017-01-31T13:51:34-06:00
Downloadable Form
Homeowners Quote Form
Personal Homeowners Online Quote Form
Step
1
of
6
16%
Requested Effective Date
MM slash DD slash YYYY
Insured Personal Information
Insured's Name
*
First
Last
Should match name(s) on deed.
Email
*
Enter Email
Confirm Email
Phone Number
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Highest Education Completed
*
High School
Associate's Degree
Bachelor's Degree
Law or Medical Degree
Is the insured a member of AARP
*
Yes
No
Insured SSN
*
DOB
*
Marital Status
*
Single
Married
Divorced
Occupation
*
Have you moved in the last 3 years?
*
Yes
No
Please enter previous address
Add a Co-Applicant?
*
Yes
No
Co-Applicant
Insured's Name
*
First
Last
Should match name(s) on deed.
Highest Education Completed
*
High School
Associate's Degree
Bachelor's Degree
Law or Medical Degree
Insured SSN
*
DOB
*
Occupation
*
Insured Amounts
Dwelling Amount:
*
Water Backup Limit
*
Sump pump?
*
Yes
No
Liability Limit
*
Deductible
*
Jewelry/Furs/Fine Arts/Etc
*
Medical Payments
*
Backup System?
*
Yes
No
Identify the System
*
Gas powered
Water powered
Battery powered
Whole house generator
Property Information
Year Built
*
Purchase Date
*
MM slash DD slash YYYY
Purchase Price
*
Number of Stories
*
Square Footage
*
Architecture Style
*
Choose One
Ranch
Split Level
Colonial
Other
Number of Bathrooms
*
Choose One
1
1.5
2
2.5
3
3.5
4
4.5
5+
Number of Families
*
1
2
3
4
Heat Type
*
Choose One
Gas
Radiator
Other
If Heat Type is "other" please describe
Exterior Type
*
Choose One
Frame
Aluminum/Vinyl
Masonry
Masonry Veneer
Stucco
Roof Type
*
Choose One
Asphalt Shingle
Tile / Slate
Wood Shingle
Tar & Gravel
Composition
Foundation Type
*
Choose One
Basement Unfinished
Basement Finished
Crawl Space
Slab
Is there a Fireplace?
*
No
Yes
How Many Fireplaces?
Wood or Gas Fireplace?
Please indicate if the property has any of the following below
Monitored Alarms
*
None
Fire Alarm
Burglar Alarm
Fire & Burglar Alarm
(If issued, you must provide alarm certificate)
Garage
*
None
Attached
Detached
Garage
*
1 Car
2 Car
3 Car
4 Car
Deck?
*
No
Yes
Square Footage of Deck?
Porch
*
No
Yes
Square Footage of Porch
Is the Porch open or enclosed
Open
Enclosed
Does the Insured have any dogs?
No
Yes
How many dogs?
Breed Type
Is the Property currently in Foreclosure?
*
No
Yes
Is the Property currently for sale?
*
No
Yes
Please select any Add-Ons the property has
Inground Swimming Pool
Aboveground Swimming Pool
Diving Board
Pool Slide
Hot Tub
Trampoline
Fire Extingusher(s)
Wood Stove
Dead Bolt
Fenced-in Yard
Is the pool Fenced?
*
No
Yes
Height Of Fence
*
Height of Fence
Does Inground pool have electric / locked cover?
*
No
Yes
Does Trampoline have enclosure net?
*
No
Yes
Is there a business in the home?
*
No
Yes
Type of Business
*
Is the Property more than 25 years old?
*
No
Yes
When were the utlities last updated? If never updated, please provide the date the utlitity was put in the home
Furnace
*
Electrical
*
Plumbing
*
Roof
*
Please select either Breakers or Fuses
*
Breakers
Fuses
Any Homeowner claims in the past 5 years?
*
No
Yes
Please explain (date/type of loss/amount paid)
*
Please provide details such as the date, the type of loss, and the amount paid.
Mortgage
Current Mortgage Company
Current Carrier
*
Number of years with Carrier
*
Expiration Date
*
MM slash DD slash YYYY
Premium
*
Has coverage been cancelled or non-renewed in the last 3 years?
No
Yes
Please provide reason for coverage being cancelled or non-renewed
*
Please enter any additional information you may have regarding this quote
Go to Top