Homeowners

ELLIS INSURANCE GROUP

Personal & Business Insurance
Individual & Employee Benefits

Homeowners Insurance

Simply complete all of the information below, for a free, no hassle insurance quote for your home.

Loan & Mortgage companies, for your convenience, you can simply complete the information on the individual and attach your appraisal to an email by clicking Appraisal.

Proposed Effective Date of Quote:
		Head of Household Spouse (if applicable)
First Name:
Last Name:
Email:
Social Security Number:		Not required, but will provide the most accurate quote
Date of Birth:
Your Occupation:
Phone 1:
Phone 2:
		Mailing Address
Street:
City:
State:
Zip Code:

Is the property address the same as the mailing?		Yes No
		If "No", Please Indicate Home Address
Street:
City:
State:
Zip Code:
		About Your Home
Current Insurance Carrier:
Current Premium:
Describe all claims or losses in the past 3 years:
Is your policy being non-renewed or cancelled?:		Yes No If Yes, the reason why:
Year Built:
Year Purchased:
Number of Families/Units:
Located in city limits:		Yes No
Any Smoke Detectors:		Yes No
Any Fire Extinguishers:		Yes No
Deadbolts on your doors:		Yes No
Is there a smoke, fire, or burglar alarm?:		Yes No If Yes, type:
Any Pets?:		Yes No If Yes, type: Describe any losses or claims as a result of these:
Is there a trampoline?:		Yes No
Type of Pool:		If outdoor, is it completely fenced? Yes No
Any smokers in the household?:		Yes No
Responding Fire Department (if known):
Distance to fire department:
How far to the nearest fire hydrant?:
How many square feet is your home?:
How many stories is your home?:
What is your primary source of heat?:		If "Woodstove" or "Other", additional information will be needed.
Type of Construction?:		If other, please describe:
Outside Wall Covering approximate percentage:		% Aluminum/Vinyl % Wood Siding % Brick % Other Masonry % Stucco %
What type roof is on your home?:
Has your home been updated?:		If yes, what year and amount? Year Amount Wiring Year Amount Heating Year Amount Plumbing Year Amount Roof
Type of Garage?:		If you have a garage is it:
Does your home have a basement?		If yes, what percentage is finished?
Type of Deck:
Number of Full Baths?:
Number of Half Baths?
Number of Fireplaces:
Number of Hearths?:
Number of Chimneys?:
Amount of Coverage Desired on your home?:		$
Amount of Liability coverage desired:
Amount of Medical Payments desired:
Desired Deductible for your home:		Unless otherwise directed by you in the Additional Comments section at the end of this form, Replacement Cost for your home and your personal property will be included in this proposal.
Do you desire sinkhole coverage?:
Do you desire earthquake coverage?:
Do you run any type of business from the home?:		If yes, please describe:
Additional comments and instructions: