Please use this form to request a home insurance quotation from The White Agency. By completing this form as accurately and completely as possible, you help us deliver to you our best possible premium.
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1. Personal information * Your Last Name: First Name: M.I. * Home Address: * City: State: Zip: Home Phone: * E-mail Address: 2. Insurance Information Do you currently have insurance on your house? Yes No If Yes which company? Expiration Date: Claims in the past 3 years? Yes No If Yes describe all claims in the past 3 years, including date and amount paid. Deductible: pick one 250 500 1000 Personal Liability: pick one 100,000 300,000 500,000 Coverage Amounts Dwelling $ Other Structures $ Personal Property $ Loss of Use $ 3. Home Information Year built: Construction: pick one Frame Manufactured Masonry Wood burning Stove yes no Trampoline yes no Swimming Pool yes no smoker nonsmoker Responding Fire Department Distance to Fire Department
Claims in the past 3 years? Yes No