Disclaimer – The premium quoted are estimates based on information you provided. This quotation does not constitute a contract of insurances, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with the signed application and a down payment.
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First Name
M.I.
Last Name
Address Line 1
Address Line 2
City
Zip Code
E-mail Address
Phone
Age
Bold = Required field
Current Policy Information
Current Insurance Carrier (Not Agency)
Policy Expiration Date
Amount Insured For
Deductible
Home Information
How long at present address?
Previous address (if less that 2 years)
Numbers of claims in the last 3 years
Year home was built
Square footage of home (excluding basement and garage)
Structure Information
Type
Construction
Age of roof
Foundation
Garage
Features
Bathrooms
# of full
Bathrooms
# of half
Basement
Sq. Ft.
Deck Sq. Ft.
Porch Sq. Ft.
Patio Sq. Ft.
Number of Fireplaces
Number of Chimneys
Number of Hearths
Additional Features
Electrical System
Amps
Heating System
Woodstove
Trampoline
Pool
If yes,
Slide/Diving Board
Height of fence
Dog
If yes, what breed?
Bankruptcy/Losses
Any bankruptcy in the last 7 years?
Any losses in the last 7 years?
If yes, please explain:
Please give any additional comments about the coverage you desire:

Home Insurance Quote

7801 North Dixie Drive
Dayton, OH 45414
E-mail: communityinsurance2000@yahoo.com

Business:  937-898-9010
Fax: 937-898-9097

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