ASJ Insurance & Financial Services Inc.

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Homeowners Quote Request

To obtain a quote please complete the following survey as completely and accurately as possible . Once submitted the information will be e-mailed to our office(s) and we will expedite your request. This information will be kept confidential and will be used for quote purposes only. We look forward to serving you.

Fields marked with a Red asterisk * are required.

Fields marked with a Blue asterisk * , at least 1 of the fields must be filled in.

Contact Information
* Name:
Address:
City:  State:   Zip:
Phone: * Work:
* Home: 
   
 Fax: 
* Email Address:

 

Current Policy Information
Current Insurance Company:
Policy Expiration Date:

Home Value to be Covered:


OR Renter's Contents:

Deductible:
($500, $1000, Other)
Liability Coverage:
($100,000, $300,000, Other)
Current Annual Premium:
# of Claims in Last 3 Years:

 

Property Information
Is Location to be Insured Same as Above: No   Yes
If 'No' Above, Please Complete Location Information:

City:  State:   Zip:
Ownership: Own   Rent
Property Is A: Home   Condominium* Townhouse Apartment
* If Condo - Number of Units in the Building
How Long at Present Address: Years Year Home Was Built
Age of:
(years)		 Roof
Wiring		 Heat
Plumbing
Fire Department Name:

Miles From Dwelling:

Nearest Fire Hydrant:

Miles

Feet

 

Structure Information
Type
Construction
Roof
Foundation
Garage
Sq. Ft.:
(excluding basement & garage)		  
 		  

 

Features
Bathrooms
Basement
Deck/Porch/Patio
Fireplaces
# of Full:
# of Half:

Sq. Ft.:
Deck Sq. Ft.:
Porch Sq. Ft.:
Screened Patio Sq. Ft.: 		# of Chimneys:
# of Fireplaces:
Woodburning Stove:
No Yes
Swimming Pool Trampoline Pets Scheduled Property

No   Yes

 # of Pets:
Claims?: 		Personal:
Computer:
Office Equip:

 

Security/Systems
Heating System
Central Air
 Dead Bolts
Security Alarm
Fire Alarm
Smoke Detector
No
Yes		 No
Yes

Extinguishers?
No Yes

 No
Yes

 

Additional Considerations/Requests
Please give any additional comments you feel appropriate for this quotation.


Please click on the "Submit Request" button to send us your quote request.

 

    

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Thursday, July 29, 2010


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