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Start a Home Insurance Quote

You are only required to complete the first section of this form in order to receive a response from an agent. Any other information you would like to enter on this form is optional.

Primary Insured

Name

Mailing Address

City

State

Zip

Home Phone

Work Phone

Cell Phone

Email Address

Date of Birth

Preferred Contact Method Email Phone

Best Time To Call AM PM

Referred By

Spouse or Additional Insured:

Name

Date of Birth

Current Homeowners Insurance Information

Company Name (not agency)

Policy Expiration Date:

Policy Type:

Premium Amount:

Dwelling Amount Insured For:

Contents Amount Insured For:

Liability Coverage Limit:

Deductable:

Hurricane Deductable:

Home Information

Address of property to be insured:

City

State

Zip

How Long At This Address?

Year Home Was Built:

Sq. Footage:

Excluding garage and basement

Occupancy

Number of Occupants

Dwelling Type

New home purchase? Yes No

Closing Date:

Purchase Price:

Structure Information

Updates to electrical? Yes No

If so, what year?

Updates to plumbing? Yes No

If so, what year?

Updates to roof? Yes No

If so, what year?

Flood zone? Yes No

How many Stories?

Construction type?

Foundation type?

Roof Type?

Age of Roof?

Roof Slope?

Second Floor Sq Ft:

Garage?

Garage Type?

Features

How many bedrooms?

How many bathrooms?

How many fireplaces?

How many porches/decks?

Porch Sq. Ft.

Deck Sq. Ft.

Screened Patio Sq. Ft.

Inside city limits? Yes No

City water and sewer? Yes No

On more than 5 acres? Yes No

Distant to fire hydrant?

Distant to fire station?

Pool Information:

Is there a pool? Yes No

Is pool fenced? Yes No

Lockable fence? Yes No

Diving board? Yes No

Pool slide? Yes No

Screen enclosure? Yes No

Sq Ft

Additional Features

Smoke Detectors? Yes No

Trampoline? Yes No

Security System? Yes No

Heating System

Cooling System

Security System Type

Acreage? Yes No

How Many?

Dogs on property? Yes No

Breed:

Bite history? Yes No

Other Pets or Animals? Yes No

Description:

Additional Comments

Have you had any bankruptcies, judgements or tax liens? Yes No

Do you own, occupy or rent any other home? Yes No

Has any coverage been declined, canceled or none-renewed in the last 3 years? Yes No

Do you own any RV's, dune buggies, mini bikes, ATV's, jet skies, etc..? Yes No

Is home undergoing any renovation or reconstruction? Yes No

Will the home be up for sale? Yes No

Do you own a golf cart? Yes No

Describe any claims/losses in the last 3 years
Please give any additional comments you feel appropriate for this quotation. If you
have additional information where there was not enough space, please enter it here

What is 5 + 2?

Submission of quote request form to this agency does not constitute a binding confirmation of new or revised insurance coverage.

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Scott Taylor Metlife Owner of the Year

© 2012 - 2013 | Taylor Insurance
1835 W. Chandler Blvd., Ste. 105 | Chandler, Arizona 85224

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