Fred Simmons Insurance


HOME INSURANCE QUOTE FORM

First Name MI Last Name

Physical Address
City State
Mailing Address
City State
Home Phone
Work Phone
Email (required)
Date of Birth
How did you hear about Fred Simmons Marketing Insurance, Inc?
What carrier are you currently with?
What is important to you when buying insurance? (5 being highest importance)
Coverage :
1 2 3 4 5
Price :
1 2 3 4 5
Reputation :
1 2 3 4 5
Value :
1 2 3 4 5
Agent :
1 2 3 4 5
Carriers name :
1 2 3 4 5

What is it that you like or dislike about your current insurance carrier?

Occupation    Spouse Occupation

Number of Claims in last 3 years: 0    1    2   3
Please give date and description of loss:
Deductible desired ($):
Schedule Personal Property
(Provides additional coverage for personal property of highter values such as jewelrey, watches, furs, etc...):

HOME INFORMATION
Is this home your: Primary residence      Secondary residence

Square footage of living area

Year of Construction
Current dwelling value:
Number of Acres Less than 1     More than 1
Type of Home:
Single Duplex Tri-plex Quad-plex Other
If Townhouse, # of Units attached:
My home is within 1000' of fire hydrant:
yes     no
Within 5 miles of fire station:
yes     no
Type of Construction:
1 Story 1 ½ Story 2 Story Split Level Bi-Level
Construction:
Frame or Stucco Masonry Veneer Masonry
Type of Roof:

Age of Roof:
Renovations?:
Plumbing, year
Wiring, year
Heating, year
Cooling, year

Protective devices:
Burglar alarm     Fire alarm     Smoke alarm     Gated community    
Fireplace type:

Comments:
CA License #OC17932

Privacy notice:
Fred Simmons Insurance Marketing, Inc. insures your privacy. We will include a copy of our Privacy Statement upon request.

This conditional quote is based on the the information you provide(d), and is subject to final approval by the carriers' underwriters.


Fred Simmons Insurance, Inc.
Design and development by NMV Inc.