603-435-7262 • 3 Leavitt Rd. • Pittsfield, NH 03263
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Homeowner's Insurance Quote
Please complete the form below for a quote on homeowner's insurance.
First Name
Last Name
Street Address
City/Town
Zip
Home Phone
Cell Phone
If Different Location, List Here
Primary Dwelling
Single Family
Two Family
Secondary
Seasonal
Tennant Occupied
Families
One
Two
Three
Four
House Information
Year of Construction
House Type
Select One
Frame
Masonry
Log
Modular
Dimensions or Square Footage
Number of Stories
Deck?
Yes
No
If Yes, Provide Square Footage
Porch?
Yes
No
If Yes, Provide Square Footage
Wiring Age
Amps of Service
Plumbing Age
Plumbing Type
Copper
PVC
Both Copper and PVC
Heating Age
Heating Type
FHW
FHA
Fuel Type
Oil
Propane
Natural Gas
Secondary Heat
if applicable
Woodstove
Fireplace
Pelletstove
Dwelling
Personal Liability
Medical Payments
Deductible
Check All That Apply
Smoke Alarms
Home Alarm System
Deadbolts
Fire Extinguishers
Smoker
Non-Smoker
Basement Type
Slab
Full Foundation
Finished
Unfinished
Garage?
Yes
No
Attached
Unattached
Dimensions or Square Footage
Other Unattached Structures?
Yes
No
If Yes, Describe Use and Value
Check All That Apply
Swimming Pool
Diving Board
Slide
Trampoline
Pets
Pet Type and Breed
Business Conducted on Property
Yes
No
If Yes, Business Type
Any Losses in the Last 3 Years?
Yes
No
If Yes, please describe and give amount
Any Scheduled Propery?
Yes
No
If Yes, please describe and give amount
Do You Currently Have an Insurance Policy in Place for This Property?
Yes
No
If Yes, Years with Company
Name of Insurance Company
Date Policy Expire
