Westan Insurance Group, Inc.

July 28, 2004

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Home Owner's Insurance > Request a Quote

Customer information
Customer name:
SSN:
Date of birth :
Occupation:
E-mail:
Customer name:
SSN:
Date of birth :
Occupation:
E-mail:

Address of property insured:
Address:
City:
Zip:

Current address if different:
Address:
City:
Zip:

Length of time at current address?


Claims in last 3-5 years?


Do you have insurance now?
Yes No
Company:

Do you have auto insurance?
Yes No
Company:

Any Bankruptcies in last 5 years?
Yes No
If yes, was it medical?
Yes No

Coverages
Dwelling:
Content:
Liability:
Med Pay :
Deductable:
Replacement on contents:	Yes No
Replacement on dwelling:	Yes No
Earthquake coverage:	Yes No
Other endorsements:


Other information
Heated Sq. Feet :
# of Baths :
Stories:
Garage:
Frame:
Year Built:
City limits :	Yes No
If no, subdivision:	Yes No
Fire Hydrant:
Responding Fire Dept:
Swimming pool:	Yes No
If yes, is the pool fenced:	Yes No
Out buildings:
Heat type:
Trampoline:	Yes No
Dogs:	Yes No
If yes, what typw of dog?
Deadbolts:	Yes No

Remodeled
	Plumbing
	Wiring
	Heat/Air
	Roof
Other:

Any other information or coverages needed: