PART ONE - Personal Information 
Name:          	
Email:         	
Address:     	
City/State/Zip:	
Work Phone:    	
Home Phone:    	

Comments and Questions:


End of Part One... Scroll down and send
or continue to the insurance quote form:

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PART TWO - Insurance Quote Form

What type of insurance quote do you need?
	 	 
    Select One
    Homeowners
    Dwelling
    Condominium 
    Renters
    Mobile Home
    Builders.Risk


Property Address:
City/State/Zip:	 

Note: Insurance policies are only available for property
in Brevard and Indian River counties in Florida.
County:	 	 
    Select One
    Brevard County
    Indian River


Effective Date Needed:
	 	 

Previous Insurance:Yes  No
		 If yes, Name of Company:
    		 
		 If yes, Expiration Date:
    		 

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House/Dwelling Value: (not applicable to Renters or Condos)
		 
Is your Residence rented to others?Yes  No

How many months per year is the Residence occupied? 
Use of Home:		 
    Select One
    Primary
    Secondary
    Seasonal 
    Vacant 

Use of Home:		 
    Select One
    Owner Occupied
    Tenant Occupied
    Vacant 


Distance to Open Water:  
Distance to Fire Hydrant:
    Select One
    0-500 Feet
    500-1000 Feet
    Over 1000 Feet
    No Hydrant

Distance to Fire Station:
    Select One
    0-3 Miles
    3-5 Miles
    Over 5 Miles

Year Built:		 
Living Area (Sq.Ft.):		
Construction Type: 	 Masonry Frame
Central Heat & Air?	 Yes  No
Roof Material:		 
    Select One
    Shingle
    Tile
    Gravel

Garage/Carport: (Check all that apply)
Carport                1 Car Garage Attached
1 Car Garage Detached  2 Car Garage Attached
2 Car Garage Detached  3 Car Garage Attached

Is your House on Stilts? Yes  No
Safety Features: (Check all that apply)
Smoke Detectors        Local Alarm
Central Alarm          Indoor Sprinklers
Storm Shutters

Does the Residence have a Pool?
(Do not include clubhouse or common area pools.)Yes  No
		 If yes, is it screened or fenced?:
		 (Fence height at least 4 feet) Yes  No

Do you have any dogs? 
		  Yes  No
		 If yes, what breed?: 
    		  

Deductible Amount 
    Select One
    $500
    $1000
    $2500


Liability Limit   
    Select One
    $100,000
    $300,000
    $500,000 


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Renters/Condo Unit-owners Only -  Value of Contents
		
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Loss Assessment Coverage (Condo Only)   
    Select One
    $1,000
    $2,000
    $5,000
    $10,000


Are the Outside Walls of your Condo insured by the Association?
(Condo Only)	  Yes  No
Value of Interior/Fixtures of condo-unit (not 
covered by the Association): 


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Are you interested in purchasing flood insurance?Yes  No
(An agent will contact you regarding the detailed
information required to quote a flood insurance policy).

Additional Coverages or Information:


You may now: