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Homeowners Quote Information Form

(* Required Field)

Name:

Disclaimer: No insurance coverage or policy change will take effect until a Hoffman Group associate advises you by phone or through written communication that coverage has been placed. If you need immediate service, please call us at (800) 826-4006.

Address:

City:

State:

ZIP:

Phone:

E-mail:

Dwelling Information:

Current dwelling coverage limit?

Year of construction?

Construction type?

Years of updating (if applicable)

Item	Year Updated
Roof
Heating
Plumbing
Electrical

Number of stories?

Finished Basement?

Square feet of living area?

Number of Fireplaces?

Number of Bathrooms?

Garage (# of cars)?

Attached?

Air conditioning?

Discounts

Smoke dectors		Dead bolt locks on all exterior doors
Fire extinguishers		Central station alarm

Deductible

Personal Property Limit?

Any losses last 5 years?

Mortgagee

Please list any pets including breed?

Trampoline?

Pool?

Any scheduled property?
(include jewelry, fine arts, etc.)

Liability Limit

Do you currently have a personal umbrella policy?

Recreational Vehicles

Current Insurance Company

2 Berea Commons, Suite 10 Berea, Ohio 44017	5329 N. Abbe Rd. Suite 4A Elyria, Ohio 44035	5000 Foote Road Medina, Ohio 44256
	1.800.826.4006