Leffelman & Associates : Obtain a Quote


HOMEOWNERS INSURANCE QUOTE	We would like to provide you with a free, no-obligation homeowners insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

PERSONAL INFORMATION

Name:

Address:

City:

State:

Zip:

Day Phone:

Night Phone:

Best Time To Call:

Email Address:

Occupation:

How long at current employer:

CURRENT INSURANCE INFORMATION

Company Name:

Expiration Date:

Premium Amount:

Amount Insured For:

Policy Type:

Term:

	6 Months
	1 Year
	Other

HOME INFORMATION

How Long at Present Address:
Year Home was Built:
Number of Claims in Past 3 Years:
Square Footage (Excluding Garage
and Basement):

STRUCTURE INFORMATION

Type:

Construction:

Roof:

Age of Roof:

Foundation:

Garage:

FEATURES

Full Bathrooms:

Half Bathrooms:

Basement:

Basement Square Feet:

Deck Square Feet:

Porch Square Feet:

Screened Patio Square Feet:

Number of Chimneys:

Number of Hearths:

ADDITIONAL FEATURES

Heating System:

Central Air:

Central Vac:

Security Alarm:

Fire Alarm:

Smoke Detector:

ADDITIONAL COMMENTS

Please give any additional comments you feel are appropriate for an accurate quote.