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First Name:     Middle Initial:  Last Name:       Sr Jr I II III IV V VI    Address 1: Address 2: City, ST  Zip: Home Phone: Work Phone: Social Security Number: (optional) - -       Date of birth :        Select the type of insurance coverage you require:  Select One I Own and need Contents Coverage I Own, but only need Contents Coverage I Own, but only need Contents Coverage I Own, but house rented to another I Rent and only need contents coverage    Year the home was built   Do you have pets? Yes No   Please estimate the total square footage of the residence:       What is the total number of floors, excluding the basement:      How many bedrooms are in the home?  Select One 1 2 3 4 5+     What is the number of bathrooms?   Select One 1 2 3 4 5+ What is the number of half-bathrooms?    Select One 1 1 1/2 2 2 1/2 3 3 1/2 4 4 1/2 5+    Is there a garage?  Yes No   Please describe the garage:   Select One Attached to Home Not Attached to Home    If your home has a garage, how many vehicles does it hold? Select One None 1 2 3 4 5+     Please describe the exterior walls of structure:  Select One All Brick More than 50% Brick Stucco Cinder Block Log Other Not Sure   Describe the type of roof on the home:  Select One Asphalt Colored Granules (Common) Wood ShakeTreated Wood Slats Tile or Clay Shingles(Spanish Roof) Metal Flat Roof Other Not Sure   Is your home located within 1,000 feet of a fire hydrant?  Yes No     Is your home protected by a security system, and if so, what type?  Select One None Sounds Alarm in home only Signals a monitoring alarm company    Please describe any homeowners/renters claims you have made in the last 5 years. Claim Type: Select One Water Damage Smoke Damage Fire Damage Wind Damage Other    Amount ($): Select One under $1,000 $1,000-$2,500 $2,500-$5,000 over $5,000 not sure Claim Type: Select One Water Damage Smoke Damage Fire Damage Wind Damage Other    Amount ($): Select One under $1,000 $1,000-$2,500 $2,500-$5,000 over $5,000 not sure Claim Type: Select One Water Damage Smoke Damage Fire Damage Wind Damage Other    Amount ($): Select One under $1,000 $1,000-$2,500 $2,500-$5,000 over $5,000 not sure     Requested deductible:  $ Select One 100 250 500 1000 2500 5000 Not Sure   Requested liability coverage:  $ Select One 100,000 300,000 500,000 1 Million Umbrella Not Sure   Requested hurricane deductible:  $ Select One 500 1000 2% 5% 10% Excluded Not Sure    Would you like Replacement Cost Coverage on Contents?      Yes  No                           8050 North University Drive Suite 205 Tamarac, FL 33321 (954) 580-BEST (2378) Fax: (954) 580-0655 Toll free: 800-478-0546 Home | About Us | The Best News | Insurances Offered | Quote Sheets | Contact Us