GENERAL SOUTHWEST INSURANCE AGENCY - HOMEOWNERS INSURANCE QUOTE REQUEST

HOMEOWNERS INSURANCE QUOTE REQUEST

We would like to provide you with a free, no-obligation homeowners insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

Name:
Address:
City:		State: Zip:
Phone:		Day: Evening:
E-mail:
Occupation:
How long at current job?		years months

CURRENT HOMEOWNERS INSURANCE INFORMATION

Company name (not agency):
Policy Expiration Date:		Premium Amount: $
Amount insured for:		$
Policy Type:
Term:

HOME / STRUCTURE INFORMATION

How long at present address:		years months	Year Built:
Square Footage (excluding garage/basement):			Number of claims last three (3) years:

STRUCTURE
Type:
Construction:
Roof:		Age of roof: years
Foundation:
Garage:		Type:

FEATURES

Baths:		Number of Full: Number of Half:
Basement:		Square feet:
Deck / Porch / Patio:		Deck sq. ft. Porch sq. ft. Screened patio sq. ft.
Fireplaces:		Number of chimneys: Number of hearths:

ADDITIONAL FEATURES

Central Air? Yes No		Heating System:
Central Vacuum? Yes No		Security Alarm:
Smoke Detector? Yes No		Fire Alarm:

ADDITIONAL COMMENTS

Please use the space below to give details about any item in this quote request that you feel are important

PERSONAL LINES DEPARTMENT	EXTENSION	E-MAIL ADDRESS
Sandi Schwandt, CISR	135	sandis@generalsouthwest.com
Garry King, CISR	125	garryk@generalsouthwest.com
Michelle Fischer, CISR	128	michellef@generalsouthwest.com
Tara Munson	130	taram@generalsouthwest.com