One Stop Insurance Solutions

Florida Homeowners Insurance

Quote Request Form

Name

 Mr.      Mrs.     Mr. and Mrs.    Ms. 

 First Name  Middle Initial

  Last Name  

Property Address

  Street Address:        

  City:                              Inside city limits? Yes  No 

  State:                   Florida  

  Zip Code:           

  County                Choose One Alachua Baker Bay Bradford Brevard Broward Charlotte Clay Citrus Collier Columbia Dade Desoto Duval Escambia Flagler Gadsden Gulf Hardee Hendry Hernando Highlands Hillsborough Indian River Jackson Jefferson Lake Lee Leon Madison Manatee Marion Monroe Nassau Okaloosa Okeechobee Orange Osceola Palm Beach Pasco Pinellas Polk Putnam St. Johns St. Lucie Santa Rosa Sarasota Seminole Sumter Suwanee Taylor Volusia Walton Washington

Is this a home you are in the process of purchasing?

  Yes  No  If yes, when do you expect to close?

Occupancy

If you currently own the home, is it insured now? Yes  No 

If yes, are you being offered a renewal?  Yes  No   If no, what is the date of NON renewal?

Tell Us About The House

Home Type

  Choose One Townhouse Single Family, unattached Other (Explain in remarks)

Purchase Price, if new purchase or Current Value of Property

Cost to Rebuild the House

(excludes the value of the land)  

Construction

 Year the house was built: 0000 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923  

If the house is over 35 years old, do you have proof that the roof, electric and      heating has been replaced?  Yes  No N/A

Choose One CBS Frame Other, Please explain in remarks  

If part CBS and part frame, check the one that is primary (0ver 50%).

If this is a townhouse:

Is it an end unit?   Yes  No N/A

How many units are in the building (under the same roof)? 1 Choose One 2 3 4 5 6 7 8+

Foundation Choose One Solid Concrete Open

Levels

Number of Sq. Ft. Under Air

(not including the garage or covered porch)

Room Count

  0 1 2 3 4 5 6 Bedrooms     

  0 1 1 1/2 2 2 1/2 3 3 1/2 4 4 1/2 5 5 1/2 6 6 1/2 Bathrooms   Choose One:  Standard  Upgraded  Designer 

Choose a category that best describes your bathrooms. If one is standard and  the other  designer, choose upgraded. 

Choose One:  Standard  Upgraded  Designer 

Choose the category that best describes your kitchen. It is common to  meet  parts of two different categories. Just do the best you can.

  List any and all extras such as intercom, solar panels, central vacuum, etc.

Discounts

Burglar Alarm

  Choose One None Yes, reports to a central station Yes, but does not report to a central station  

Hurricane Shutters

  Choose One None Yes, installed prior to 1993 Yes, installed after 1993

Retired

Yes   No

Any owner over age 60

Yes   No

Tell Us About Your Development

Name of Development

Security in Your Development

Miscellaneous

Auto Insurance

Who is your auto insurance company?

(Home Insurance sometimes can be discounted if your car insurance is through certain carriers.)

Additional Information

Home insurance quotations will include prices for hazard insurance, wind and hurricane insurance and flood insurance separately if necessary. Exact quotes for flood insurance require flood elevation certificates or flood surveys.

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