passauerandmiller.com
Home
About
Staff
Companies we represent
Insurance & Benefits
Auto Insurance
>
Auto Quote
Business Insurance
>
Business Quote
Employee Benefits
>
Employee Benefits Contact
Home Owners Insurance
>
Homeowner Quote
Medical Insurance
>
Medical Contact
Personal Insurance
>
Personal Insurance contact
Info & Tips
What Our Customers Have to Say
Contact
Homeowner Quote
No coverage is bound until you are contacted by one of our representatives
*
Indicates required field
Name
*
First
Last
Street Address
*
Street Address 2
*
City
*
State
*
Zip
*
Social Security #
*
Date Of Birth
*
Contact Information
Home
*
Work
*
Email
*
HOME LOCATION
Street Address
*
Street Address 2
*
City
*
State
*
Zip
*
RATING INFORMATION
What year was this home built?
*
What type of construction was used?
*
Frame
Masonry
Aluminum Siding
What style is your home?
*
Single Family Dwelling
Apartment Building
Condominium
How will your home be used?
*
Primary Residence
Secondary Residence
Seasonal Home
Farm
Unoccupied
Vacant
How many rooms in your home?
*
How many full bathrooms in your home?
*
How many 3/4 bathrooms in your home?
*
How many 1/2 bathrooms in your home?
*
How many square feet on the first floor?
*
What type of home do you have?
*
Single Story
Two Story
Split Level
Tri-Level
How many total square feet in your home?
*
Do you have a fireplace?
*
Yes
No
If yes, please describe what type
*
Do you have a woodstove?
*
Yes
No
If yes, please describe type and use
*
Do you have a garage?
*
Yes
No
If yes, please describe what type
*
Attached Single Car
Attached 2 Car
Attached 3 Car
Detached Single Car
Detached 2 Car
Detached 3 Car
Carport
What is your primary source of heat?
*
What is your secondary source of heat?
*
Do you have a security system?
*
Yes
No
If yes, please describe what type
*
Have you had any losses in the past 3 years?
*
Yes
No
If yes, please describe
*
Is this your first home?
*
Yes
No
If no, do you have current insurance?
*
Yes
No
If yes, Please describe
*
Any hot tub, swimming pool, sauna etc?
*
Yes
No
If yes, Please describe
*
Any updates that have been done on home, (i.e., new roof, electrical, heating, retrofitting, etc).
*
Yes
No
If yes, Please enter date complete and describe
*
COVERAGE INFORMATION
Do you want earthquake coverage?
*
Yes
No
Do you have collections worth over $500?
*
Yes
No
If yes, Please describe
*
Do you have any single piece of jewelry valued over $500?
*
Yes
No
If yes, Please describe
*
Do you have work tools that need coverage?
*
Yes
No
If yes, Please describe
*
Do you operate a business out of your home?
*
Yes
No
If yes, Please describe
*
Submit
Home
About
Staff
Companies we represent
Insurance & Benefits
Auto Insurance
>
Auto Quote
Business Insurance
>
Business Quote
Employee Benefits
>
Employee Benefits Contact
Home Owners Insurance
>
Homeowner Quote
Medical Insurance
>
Medical Contact
Personal Insurance
>
Personal Insurance contact
Info & Tips
What Our Customers Have to Say
Contact