To receive an accurate quote, please fill out the following form as completely as possible, making sure to enter your phone number(s) correctly below.  We will review your request and call you with a quote within one or two business days. If you prefer, you may print out this form and fax it to us at (352) 728-3996.       

Fields marked with *are required.  Note that additional fields may be required as indicated depending on the answers to certain questions.  When you are finished filling out the form, please click the "Submit" button at the bottom of the page.

Contact Information
  
*First name MI *Last name
*Home phone () -
Other phone () -
Email address
When is the best time to contact you?
  
Current mailing address
  
Address 1
Address 2
City State ZIP
Location of address to be insured
  
*Address 1
Address 2
*City *State *ZIP
If the home is located in a subdivision, what is the name of the subdivision?
 
*Is the home located in the city limits?
Yes No 		 
What is the distance to the nearest fire hydrant?
  
What is the distance to the nearest fire department?
  
How did you hear about us?
  
If a person referred you, what is their name?
  
If another agent referred you, who was it?  Do you have other insurance with him/her?
  
If you are just buying the home, when is your closing date?
  
What date will you move in?
  
If you already own the home, when does your present insurance expire?
(MM/DD/YYYY)		  
If you already own the home and you are looking for new insurance, what company are you currently with?
  
*Whose name(s) will be on the deed?
  
*Who will be living in the home?
  
*Is there a loan on the home?
Yes No 		 
If yes, what is the name of the lender?
  
If you have or will have a loan, is the loan escrow?
Yes No 		 
*How many months out of the year will you live in the home?
  
If you live in the home less than 12 months out of the year, will you rent out the home at any time?
Yes No 		 
If you rent the home out, how many months out of the year do you rent it?
  
First Owner
  
*What is the first owner's occupation?
  
*What is the first owner's date of birth?
(MM/DD/YYYY)
What is the first owner's social security number?
  
Second Owner
  
What is the second owner's occupation?
  
What is the second owner's date of birth?
(MM/DD/YYYY)
What is the second owner's social security number?
  
Construction Details
  
*What year was the home built in?
(YYYY)		  
If the home is older than 20 years, answer the following:
 
  Does it have circuit breakers or fuses?
  What date was the electrical system updated?
  Is the plumbing PVC or galvanized?
  What date was the plumbing updated?
 
*Is the home frame or concrete block?
  
If frame, is the exterior aluminum, vinyl, wood, brick, or other?
  
If masonry, is the exterior brick, stucco, plain block or other?
  
*What type of roof does it have?
  
How old is the roof?
  
Is the roof gable or hip?  (A hip roof slants on all sides)
  
*What type of heating system is in the home?
  
What is the approximate age of the heating system?
  
*Is there a fireplace?
Yes No 		 
*Is there a wood burning stove?
Yes No 		 
*What is the square footage of the heating/cooled area?
sq ft		  
*Is it one story or two?
One Two		  
*How many bathrooms?
  
Garage/Carport
  
*Do you have a garage or carport?
Yes No 		 
If yes, how many cars will fit in it?
  
Porch
*Does the home have a porch?
Yes No 		 
If yes, what size?
x (length x width in feet)		  
If yes, what type of roof does it have?
  
If yes, does it have windows?
Yes No 		 
Swimming Pool/Hot Tub
  
*Is there a swimming pool or hot tub?
Yes No 		 
If yes, what was the total cost, including the enclosure, if applicable?
$ 		 
If yes, is there a diving board or slide?
Yes No 		 
Home-based Business
  
*Is there any business (including Avon sales, childcare, etc) conducted on the premises?
Yes No 		 
If there is any business conducted, please describe:
  
Boat
  
*Do you own a boat?
Yes No 		 
If yes, do you need coverage?
Yes No 		 
Golf Cart
*Do you own a golf cart?
Yes No 		 
If yes, do you need coverage?
Yes No 		 
If you need coverage on the cart, please provide year of cart:
(YYYY)		  
Make of cart:
  
Value of cart:
$		  
Pets/Animals
*Are there any animals on your property?
Yes No 		 
If yes, how many and what breeds?
  
Any history of biting?
Yes No 		 
*Is there a trampoline on the premises?
Yes No 		 
*Do you own the land where the home is located?
Yes No 		 
*Do you need any floaters for scheduled property such as: jewelry, furs, cameras and related equipment, golf equipment, postage stamps, coins, firearms, fine arts, musical instruments, silverware?
Yes No 		 
If yes, please tell us which items and a total value for each category:
  
*Have you filed any claims within the last five years?
Yes No 		 
If yes, provide description(s) and date(s) and amount(s) paid out:
Unattached Structures
Do you have any structures that are not attached to the home? This means structures set apart from the home by a clear space such as a shed out in the back yard, a boat dock, etc.  If so, please list them below.
Description Length Width Value $
Description Length Width Value $
Description Length Width Value $
Our companies will check your financial responsibility.  Have you had any repos, judgments, late payments or bankruptcy?
Yes No
If yes, when?
*If you already own the home, is the home currently for sale?
Yes No
*What is your total purchase price including land value?
$
*What amount do you feel we need to insure the home for?  (do not include land)
$
If you have any comments or notes for us, please provide them in the area below:

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