products liability - Homeowners Insurance Quote Request

DISCLAIMER

We are committed to protecting the personal privacy and security of individual consumers who seek or acquire products through one or more of our insurance programs primarily for personal, family, or household purposes ("Consumers"). While information is the cornerstone of our ability to provide you with superior service, we realize that our most important asset is your trust. Therefore, we have implemented strict privacy and security policies on our websites to ensure that no personal identifying information about individual consumers is accessible to the general public. For more details, please review our security statement below.

Depending on the type of insurance program offered to Consumers, your insurance agent/broker may submit personal information about you, others in your household and your vehicles to provide accurate insurance rates to us. This information may be submitted to us electronically via our website. Depending upon your state of residence, this information requested could include: zip code, date of birth, gender, marital status, prior insurance carrier, driving record, vehicle attributes, annual mileage, homeownership and employment. Additional information about you may be submitted to us if you purchase a policy. As permitted by law, we may confirm the information you provide through consumer reporting agencies, publically available records, appraisals or investigatory sources, and/or the Department of Motor Vehicles.

We do not sell any Consumer information to third parties. If you purchase a policy through one of our programs, we may share information about you with the following:

A third party if it is necessary to effect, administer, or enforce your insurance transaction, such as policy processing or claims administration;
Any of our affiliated companies who provide service to you;
Insurance regulatory or government authorities as required by law;
Law enforcement agencies to protect our interest or to report illegal activities;
In response to a valid legal subpoena or court order; and
Persons or organizations conducting actuarial or other statistical studies.


» Name:
Address:
City:
State:
Zip:
» Home Phone:
Work Phone:
» Email:
Age:

Insurance Type:	Single Family Townhouse Condo Renters
If multi-family bldg, how many residential units:	1-4 5-12 12+
Construction Type:	Frame Masonry Masonry Veneer
Year Built:
Nearest Fire Hydrant:	under 1000 feet none
Nearest Fire Department:	1 2 3 4 5 5+ miles
Smoke Detector:	Yes No
Deadbolt Locks:	Yes No
Fire Extinguisher:	Yes No
Central Station Fire Alarm:	Yes No
Central Station Burglar Alarm	Yes No
Swimming Pool:	Yes No
If yes, is it fenced in:	Yes No
Wood Burning Stove:	Yes No
Do you have a dog:	Yes No
Market Value $:
Existing dwelling coverage amount $:
Desired Coverage Amount $:
Liability Limit $:
Deductible:	250 500 1000
Any special coverages:
Current Insurance Company:
Expiration date (or settlement if new purchase):
Any claims past 5 years:
Please use the space below to add comments regarding any special circumstances.