QUOTE REQUEST

[AUTO] [HOMEOWNERS] [LIFE] [COMMERCIAL] [PRIVACY]

Homeowners Insurance Quote Request

Please complete the following form and press "submit". Your information will automatically be forwarded to our agency. The information you provide will be kept confidential between you and our office.

Name:
Address:
City:
State:	Zip:
Telephone:
Fax:
E-Mail:
Age of Insured:

Some of the following questions may require information contained on your current homeowners policy. If you do not have your current policy available for review leave the "answer" provided. You may leave comments or questions at the end of the questionnaire.

Residence Information

Homeowner Form
Inside City Limits	Yes No
Primary or Secondary Residence
Year Built
Construction Type
Deductible Amount
Value of Residence:

Coverages Information

Personal Liability
Medical Payment
Replacement Cost Contents:	Yes No
Replacement Cost Dwelling:	Yes No

Protective Devices

Smoke Detector	No Yes
Dead Bolt Locks	No Yes
Fire Extinguisher	No Yes
Non-Smoker	No Yes
Central Station Repeating Burglar Alarm	No Yes
Central Station Repeating Fire Alarm	No Yes
Police Station Repeating Burglar Alarm	No Yes
Fire Dept. Repeating Fire Alarm	No Yes
Local Burglar Alarm	No Yes
Local Fire Alarm	No Yes
Auto Sprinkler - All Areas	No Yes
Auto Sprinkler - Exc. Attic, Bath	No Yes

Additional Coverages

Increased Special Limits
Enter the amount of "special" coverage you would need for each category listed below.

Jewelry:
Money:
Securities:
Silverware:
Guns:

Scheduled Property

Silverware:
Camera:
Musical Inst.:
Personal Furs:
Personal Jewelry:
Jewelry in Vaults:
Guns:
Golf Equipment:

Additional Liability

Earthquake Coverage
Credit Card, Forgery
Town/Row House
Wind/Hail Excluded	No Yes

Use this area for any special comments or coverages which need special attention.

What is the expiration date of your current policy?
Which company currently provides your homeowners insurance?

165 E. Water Street - Hughesville, PA 17737 - 570-584-3161

Offering Your Insurance Solutions

Lockard Agency Inc.