Jack Rice Insurance

HOMEOWNERS QUOTE REQUEST

Please note that this form is for a REQUEST ONLY. By submitting this form it does not bind coverage in any way. If you do not hear from us in a reasonable amount of time, ASSUME WE DID NOT GET THIS REQUEST FOR AN INSURANCE QUOTE, and call our office.

I understand that filling out and submitting this form DOES NOT bind coverage in any way, and the only way coverage can be bound will be when I am informed of a binder or policy is issued by the agent representing me. Please note that coverage cannot be bound or changed by using the Internet or Email.

Information
Name:
Address:
City:
State:
Zip:
Day Phone:	Eve. Phone:
Beeper:	Cell Phone:
E-mail Address:
Best Time To Contact:	AM PM
Method of contact:	Day Phone Eve. Phone Beeper Cell Email
Current Policy Information
Agent:
Insurance Company:
Policy Number:
Policy Expiration Date:

Dwelling Information
# of Stories:
Construction:
If "Other", specify:
Additional Info:
Property Secondary Residence	Yes No
Is Property Occupied by:	Owner Tenant
Tenant Content:	Yes No
Type of Roof:
If "Other", specify:
Roof Covering:
If "Other", specify:
Garage:
Attached Porches/Carports:
Foundation Type:
Amount of Insurance Requested on Dwelling:	$ (Replacement Cost, not Market Value)

Utilities Updated in the last 20 Years:
Heating:	Yes No	Year Updated:
Wiring:	Yes No	Year Updated:
Roof:	Yes No	Year Updated:
Plumbing:	Yes No	Year Updated:
Full Circuit Breakers:	Yes No	Year Updated:

Liability Limit for All Cars

Bodily Injury

Property Damage

UnInsured Motorist Limit for All Cars

Stacked?
Yes No

Amenities

Number of Bathrooms:

Basement:

Yes No

Deck:

Yes No

Porch:

Yes No

Patio:

Yes No

Number of Fireplaces:

Central Air:

Yes No

Security Alarm:

Yes No

Fire Alarm:

Yes No

Smoke Detector:

Yes No

Additional Information Section
In the box below, please provide any additional information you feel may be necessary for us to provide you with the best quote possible such as additional operators, coverages extenuating circumstances, etc.