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Request Your FREE Home Insurance Quote

Please fill out as much information as possible. If you have any questions about this form, please contact us.

How did you find us?
Home closing date
Renewal date
Current Home Insurance Company
First Name:
Last Name:
D.O.B.
Is your credit  Good      Fair       Not Good
Property Address:
City:
State:
Zip Code:
Is it a home or a condo?  Home      Condo
Are you in a development?
If yes, name of development:		  Yes      No
Is it gated?  Yes      No
Home Phone:
Office Phone:
Cell Phone:
Fax:
Preferred contact method:
E-mail address:
WARNING: Only those requests containing a valid email address will be answered and quoted.
Mailing Address:  
City:
State:
Zip Code:
Do you want flood insurance?  Yes      No
Bankruptcy or foreclosure?  Yes      No
Year built
Roof type
Amount of coverage for home
Construction
Number of Floors
Any unattached structures?  Yes      No
If over 15 years old, has the electric,
plumbing or roof been updated?
Do you own a boat?
 Yes      No
Make
Horsepower
Length
Outboard?  Yes      No
Number of bedrooms
Number of bathrooms
Square feet under air
Garage?  Yes      No
Number of cars
Do you have a golf cart?  Yes      No
Storm shutters?  Yes      No
Patio/Deck?
If yes, square feet?		  Yes      No
What deductible?  $500      $1,000      $2,500
Pool?
Yes      No
Screened
Fenced
Central alarm
Fire
Burglary
Additional Amounts
Jewelry
Guns
Fur
Art
Business use  Yes      No
Part-time rental  Yes      No
Occupancy  Owner      Tenant
Number of occupants
Smokers?  Yes      No
Do you have a dog?
Yes
No
Breed?
Foundation  Open      Closed
Residence type
Primary
Secondary
Seasonal
Tenant
Is your water on City water or well water?  City      Well
Claim experience
last five years:
Do you have a personal Umbrella?  Yes      No
Have you ever discussed this with your agent?  Yes      No
Who insures your autos?
If I meet your expectations on this Home Quote, will you give me an opportunity to write your auto?  Yes      No
                                   

Submitting an insurance quotation request to Tim Shaw Insurance Group does
not constitute a binding confirmation of new or altered insurance coverage.
Verbal or written confirmation must be obtained from Tim Shaw Insurance Group
to confirm binding or altering coverage.

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