Fred Simmons Insurance


HOME HOBBY-FARM INSURANCE QUOTE FORM

First Name MI Last Name

Physical Address
City State
Mailing Address
City State
Home Phone
Work Phone
Email (required)
Have you had continuous coverage for the past 12 months? yes      no
If no, please explain:
Present Home/Farm Insurance Carrier
Present Home/Farm Insurance Coverage Amount $
Present Home/Farm Insurance Deductible $ Renewal Date

Occupation    Spouse Occupation

Number of Claims in last 3 years: 0    1    2   3
Please give date and description of loss:
 

FIRE PROTECTION
Distance to responding fire station:
Under 5 miles 5 - 10 miles over 10 miles
Do you have a public/city fire hydrant within 1,000 ft. of your home? yes      no
If no public/city water; Primary Water Source is:
Well Holding Tank Pond/Pool None
Number of Gallons Held:
Pump Speed (# of gallons per minute):
Secondary Water Source:
Well Holding Tank Pond/Pool None
Number of Gallons Held:

HOME INFORMATION

Square footage of living area
Year of Construction
Number of Acres

Type of Construction:
1 Story 1 ½ Story 2 Story Split Level Bi-Level
Construction:
Frame or Stucco Masonry Veneer Masonry
Foundation:
Basement Crawl Space Slab
Roof:

Age of Roof:
Garage:
1-Car 2-Car 3-Car 4-Car

Attached Detached Basement Built-in Car Port
Other Features:
Central Air Conditioning       Wet Bar Security System       Central Vacuum       Whirlpool Tub      
Fireplaces:
# of Chimneys
1 2 3 4 5
Basement: Finished n/a      yes      no Square Ft.
Deck,Porch, Patio
Deck
Sq. ft. 		Screened Patio
Sq. ft. 		Porch
Sq. ft. 		Enclosed Porch
Sq. ft.

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.
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