Home Quote - Charlie Harris Insurance Agency, Inc.

Homeowner's/Renters/Condo Quote

 
Policy Holder
Contact Name*
Email*
Phone Number*
Date of Birth
Social Securtity #
Occupation
Property Location
Address
City
State
Zip Code*
County
Current Insurance Information
Company Name
Current Annual Premium
Expiration Date
Insurance Information
Deductible Desired
Amount of Liability Desired
Hurricane Coverage Desired?  
Earthquake Coverage Desired?  
Windstorm Coverage Desired? (not applicable in all states)  
If Any Pets, What Breed?
Dwelling Information
Estimated Replacement Cost
Square Footage
Year Constructed
Is Your Home over 20 Years Old? If so, What Updates Have Been Made?
Age of Hot Water Heater?
Roof Type and Age?
How Many Floors?




Type of Construction




Other Home Features
(check all that apply)




Located within 5 miles of Fire Station
Located 1000 feet from Fire Hydrant
Claims
List any claims in past 3 years:

Date of Claim Amount Paid Claim Type Description
1.
2.
3.
Personal Property
Estimated value of your personal property:
Jewelry & Watches
Furs
Silver
Firearms
Stamp and Coin Collections
Fine Arts and Breakable Items
* = Required Field