Landfried-Fanta Insurance Agency

Homeowner's Quote

Policy Holder
Contact Name *
Email
Phone Number *
Once your basic contact info has been entered you may submit this form at anytime for an agent to contact you. How would you like to be contacted? Email
Phone
If by phone, list when is good for you:
Property Location
Address *
City *
State *
Zip *
County
Current Insurance Information
Company Name
Current Annual Premium
Expiration Date
Deductible Desired
Amount of Liability
Earthquake Coverage Desired? Yes  No
Have you filed for bankruptcy within the past 7 years? Yes  No
Dwelling Information
Estimated Replacement Cost
Square Footage *
Year Constructed *
How Many Floors? * 1 Story
1.5 Story
2 Story
Bi-Level
Tri-Level
Other
Type of Construction * Frame
Masonry
Brick Veneer
Stucco
Aluminum Siding
Single Wide
Double Wide
Other
Other Features
(check all that apply)		 Dead Bolts
Smoke Detectors
Fire Extinguisher
Central Station Fire Alarm
Central Station Burglar Alarm
Home Located within 5 miles of Fire Station
Home Located within 1000 feet of a Fire Hydrant
Swimming Pool
Trampoline
Home located within City Limits
Claims
List any claims in past 3 years:
  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
Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.
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