Gleason Insurance Agency Tewksbury MA Meeting All Insurance Needs

FINANCIAL SERVICES

INVESTMENTS

HOMEOWNERS INSURANCE QUOTE FORM
(Including Condo & Tenants Policies)

Thank you for the opportunity to quote your home insurance. Since a lot of information is required to prepare a quote, the quickest way to receive a proposal is to call one of our customer representatives directly to review your needs and provide the information we need.

However, if this is not feasible or you wish to work on-line, please fill out the questionnaire below and transmit it to our office by clicking the "Submit form" button. Since an accurate quote is dependent on many underwriting factors including loss history, credit reports and dwelling replacement cost, we may have to obtain missing information from you before issuing a firm quote. Once completed, we will mail, e-mail or fax the quote to you.

Please fill in the form below to inform us of your HOMEOWNERS INSURANCE needs.
This will allow us to contact you with for additional information or to deliver our proposal.

Your e-mail address: example: johnsmith@yahoo.com
Home phone: Work phone: Cell phone:

How do you prefer we contact you:

Owner's Name:
Co-Owner's Name:
Mailing Address:
City/Town:          State:              Zip:

Physical Adress of property to be insured:
Street:
City/Town: State: Zip:

Dwelling Information................................................................

Occupancy:

Primary Residence (yes, no):

How many family units in dwelling?

Other structures on propety? (yes, no):

Year of Construction :

Style of Dwelling :

Is this a new purchase?(yes,no):

Year of Purchase:

Your Estimate of Market Value :

Approx. sq. ft. living area if known:

Central Station Alarm? (yes,no):

No. of bathrooms (full & half) :

Garage type:

Finished Basement?

Type of heating fuel:

Central Air?
Wood Stove ?
Fireplace ?
Swimming pool? Above or below ground?
Trampoline?

Indicate year of update if different from year of construction (example: 1998):
Heating System: Wiring: Plumbing: Roof:

If you own a dog(s), please state breeds:
Please state any other animals on premises:

Is there any business conducted on the premises?

Has any owner of the property had a bankrupcy in the last 5 years?

Have you had any claims in the last 5 years ?

Current Insurance Information ................................................................
Current Insurance Company
Annual Premium $
Date Policy Expires (mm/dd/yy)

Current Coverage (Refer to Current Policy) ................................................................
We will do our own estimate of the replacement cost, but please include here:

Replacement Cost of Home (house only)

Replacement Value of Contents (if renters or condo)

Liability Limit:
Medical Payments to Others:
Deductible:

Amount & type of special scheduled items:

Earthquake coverage?
Flood coverage?:
Umbrella needed?

Please include any comments or claims history details:

By carefully filling out this form, you have entered enough information for us to compute an estimated replacement cost and quotation. Since an accurate quote is dependent on many factors and additional underwriting criteria including credit reports and loss history, we must discuss these things with you before issuing a firm quote.

To send us your information, please click the "Submit form " button below :