Americhoice Agency, Inc.
Homeowners Insurance Quote Request
PRIVACY STATEMENT:  ALL INFORMATION IS COMPLETELY CONFIDENTIAL AND IS ONLY USED FOR OUR QUOTING PURPOSES.
* = Required Field     
Please complete the following form and hit the "Submit" button to send.
First Name*
Last Name*
Address*
City*
State*
Zip*
Evening Phone*
Daytime Phone*
E-mail Address
 
Date of Birth*
  Year* (yyyy)  
Occupation*
 
Credit History*
 
 
 
Please complete this information for the property to be insured.
Address*
City*
State*
Zip*
Stories*
Bedrooms*
Bathrooms*
Fireplaces*
Garage*
 
 
Dwelling Type*
 
 
Square Footage*
 
 
Year Built*
 
Usage*
 
 
Foundation or Basement*
 
 
Construction Type*
 
 
Exterior Type*
 
 
Roofing Type*
 
 
Heating Type*
 
 
Security System*
 
 
New Purchase?*
Yes  No  
Is the property located in a flood plain?*
Yes  No
Do you currently have flood insurance?
Yes  No
Do you have any of the following breeds of dogs: Chow, Doberman, German Shepherd, Pitt Bull, Rottweiler, Wolf Hybrid, or a mix of these?*
Yes  No
 
Prior Coverage Information
Is the property currently insured?*
Yes  No
How long have you had continuous insurance coverage?
  (years)
Prior Carrier Name
Prior Policy Number
Prior Policy Expiration
  Year (yyyy)
Years at this residence*
Years at previous residence
 
Past Claims
Claims in past 5 years*
 
Date of Claim 1
  Year (yyyy)  
Claim 1 Type
Claim 1 Amount
 
Date of Claim 2
  Year (yyyy)  
Claim 2 Type
Claim 2 Amount
 
Date of Claim 3
  Year (yyyy)  
Claim 3 Type
Claim 3 Amount
 
Date of Claim 4
  Year (yyyy)  
Claim 4 Type
Claim 4 Amount
 
Limits of Insurance For Quote
Liability Coverage*
Requested Deductible*
Approximate Value of Property*
Approximate Value of Contents*
Are you interested in Mortgage Protection Coverage?*
Yes  No