Your name 

Day phone 

E-mail        

Name & Address

Name(s) of home owner(s)

If married, please list both parties

Property Address              

City                                      ZIP  

Reason for Purchase of Insurance

Upcoming Purchase    Purchase Price    Projected Closing Date

Replace Current policy     Company   Expiration Date

Replace Cancelled Policy     Company   Days since cancelled 

Reason prior policy was cancelled or non-renewed (if applicable):

What does your prior insurance have to do with anything?

About Your Home

Please provide as much information as possible.  Incomplete information may result in a change in the quote or policy when insurance is written.

Estimated or appraised value of home, including land

Square Feet    Number of Stories    Number of bathrooms 

Year Built   Exterior wall material  (brick, vinyl, wood, etc.) 

Distance in feet from fire hydrant 

Distance in miles from fire station   Name of fire station

What years were the following systems last upgraded or replaced?

Roof   Heating Unit    Electrical System    Plumbing 

If you own any dogs or exotic pets, please list breeds or species:

Please check any of the following that apply

Central Gas heat

Central Electric heat

Other heat  (describe) 

Central Air conditioning

1-Car Garage

2-Car Garage

1-Car Carport

2-Car Carport

Wood-burning Stove

Swimming Pool

Trampoline

Smoke Detectors

Deadbolt locks on all exterior doors

Fire Extinguisher

Monitored Burglar Alarm

No Smokers in household

Personal Information

In general, how is your credit? 

Have you:  filed for bankruptcy?    Had a repossession? 

Please provide the following information for all owners:

Date of Birth                         

Social Security Number         

I prefer to call Sauls Insurance at 256-8983 and give my social security number by phone, so this quote request can be processed.

By submission of this request, I authorize Sauls Insurance Agency to obtain credit scores to provide me with the best possible quote.

Click this icon for an explanation as to why this information is needed.

What claims have you had in the past 5 years?  Please list approximate dates, descriptions, and amounts paid.

Do you own any large amounts of jewelry, silver, guns, or anything unusual?

Any additional information?

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