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Homeowners' Quote

 

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Kozhuharov Insurance Agency
Toll Free: (877) 205-0051
Fax: (269) 441-5163
E-mail: deyan@kozhuharovagency.com

Homeowners' Insurance Quote Request

Effective Date:
Your Name:
Your Mailing Address: Street

City & State                                                     Zip
  
E-mail Address:
Daytime Phone #:
Choose One: Please call me with quote premium.
Please send quote via e-mail.
Current coverage: Company:                                       Expiration Date:
 
Type of policy desired:
 
 
Amount of insurance desired:
 
Homeowners only:
What is the value of your home?

Condo/Renters only:
What is the value of your personal property?
Liability Limit:


Medical Payments:
Valuation of Home:

Personal Property Valuation:
 		Deductible:
Property Information:
 
What is the construction type of your home?
 		In what year was your home built?
In what County/Township are you located?
 		Distance to the nearest fire hydrant?
What kind of pets do you have?
 		Do you have a swimming pool?
 Yes No
Do you have a trampoline?
 Yes No 		Do you use a wood burner?
 Yes No
Smoke Detector(s) Installed
 Home Security System Installed
 		  
Home Updates:  Enter year updates were made. If year not known, enter "unknown":
Roof:


Wiring:
 		Plumbing:


Heating:
Optional Property Coverages:
 
Earthquake Coverage Requested
 Flood Coverage Requested
 Sewer/Water Backup Coverage Requested
 
Property Floaters - Indicate limits below:
 
Antiques:

Coins:

Computers:

Fine Arts:
 		Furs:

Jewelry:

Stamps:

Tools:
Other Floater Coverage:     Limit of Insurance:
 
Previous Loss Information
 Please describe any losses or claims filed on your Homeowners Insurance in the last 3 years:

Date of loss:                                Type of loss:                                         Amount of claim:
Additional Comments
Please use the box below to enter any additional information you wish to include:

We cannot bind coverage from an e-mail or voicemail request. Coverage is bound after you receive a written e-mail or telephone confirmation from an agency staff member.

If you have not received a response from us within one business day, please contact us again.

Thank you.



 

 

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Send mail to deyan@kozhuharovagency.com with questions or comments about this web site.
Copyright © 2008 Kozhuharov Insurance Agency
Last modified: 08/11/11