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Request a quote for your Homeowner's Insurance

Lewis Insurance Associates will soon be offering you the ability to request a free, confidential quote online using the form below.

( * indicates required information)

GENERAL INFORMATION:
*Applicant Name:
*Applicant Date of Birth:	Mo. Day Year
*Social Security Number:
Spouse's Name:
Spouse's Date of Birth:	Mo. Day Year
Social Security Number:
E-mail address:
*Daytime Phone Number:
Alternate Phone Number:
*Current Address:
*City:
*State:	*Zip Code:

RESIDENCE INFORMATION:
*Residence Address:
*City:
*State:	*Zip Code:
*Closing Date:	Mo. Day Year
Purchase Price:
Is appraisal being done:	Yes No
Mortgage Company Contact:		Phone Number:

*Are you currently insured:	Yes No
Current Insurance Carrier :
Exp. Date of Current Insurance:	Mo. Day Year
What coverages do you currently carry:	Dwelling Deductible Liability Medical
*Has any company declined, cancelled, or refused to renew similar insurance? (Non-pay cancellation or previous carrier request that coverage be purchased from another company is the same as being cancelled or declined.):			Yes No
If yes, give reasons:
*Has the applicant had any loss, such as fire, windstorm, theft, liability, etc., on this or any other property within the last 5 years?:			Yes No
If yes, give date:	Mo. Year	If yes, give amount:
If yes, give reason:
If yes, give date:	Mo. Year	If yes, give amount:
If yes, give reason:
*Is the applicant conducting any business, farming, or occupational pursuits at the premises?			Yes No
If yes, what kind:
*Year home was built:	*Type of Construction:
Does the home have a fireplace:	Yes No
Is there a wood-burning stove:	Yes No
If yes, is it UL certified and professionally installed:	Yes No
RESIDENCE REPAIRS: Please list updates if home is over 25 years old.
Roof:	Repaired Replaced Original Mo. Day Year
Electrical System:	Repaired Replaced Original Mo. Day Year
Heating/AC:	Repaired Replaced Original Mo. Day Year
RESIDENCE SYSTEMS AND OTHER FACTORS:
Type of Electrical:	Circuit Breakers Fuses Amps:
Type of Heating:	Gas Electrical
*The nearest fire-hydrant:	feet from the home.
*Miles to the nearest Fire Dep't:	Name of Fire Dep't:
Does the home have Smoke Detectors:	Yes No
Does the home have Deadbolt Locks:	Yes No
*Do you have pets:	Yes No
If yes, please describe:	Type Breed Qty. Type Breed Qty. Type Breed Qty.
Have they ever attacked anyone:	Yes No
Please list any jewelry, furs, silver, guns, fine art, or other objects you would like covered?:	Value Description Value Description Value Description


In order to give you the most accurate quote, we will need to run a few reports. The reports are a Clue Report, which shows prior claims and, an Insurance Score, which will contain credit information. In order to run these reports and obtain a quote for you we need your permission. In some instances, we will be unable to provide you a quote without this informatin. By submitting this request for a quote you are giving us permission to obtain this information. Any information which we have or may obtain about you or other individuals listed as policyholders on your policy will be treated confidentially. You have the right to see personal information collected about you and you have the right to correct any information which may be wrong. Upon your request the address of the reporting agency will be supplied so that you can request this information.
REMEMBER! Completion of this form constitutes a request for a quotation. It is not intended to replace or act as an actual insurance contract or binder.