Paquin & Carroll Insurance

Homeowners Insurance: Premium Quotation Request

Contact Information
* First Name
* Last Name
* Address
Address 2
* City
* State
* Zip
* Day Phone
Evening Phone
Fax
* E-Mail

Group Affiliation:

Home Description
* Construction	Brick Frame
Year Built

Please advise the date the following items have been updated if home is over 20 years old (if under 20 years old please enter "NA"):
* Plumbing
* Heating
* Electrical
* Roof

Is your home within 3 miles from a Fire Station?
	Yes No

Is your home within 500 feet from a Fire Hydrant?
	Yes No

Do you have smoke detectors?
	Yes No

Do you have fire extinguishers?
	Yes No

Are you a non-smoker?
	Yes No

If you own autos, would you be interested in combining the autos with the homeowners policy for additional discounts?
	Yes No

Coverage Limits
* Dwelling
* Contents
* Liability
Deductible
List any items which you desire to have scheduled for an agreed amount , i.e. Jewelry, Furs, Silverware:

General Information
Have you had any homeowner claims or losses within the last 3 years? If so, please explain:

Do you have a swimming pool?
	Yes No
If so, is the pool completely fenced in?
	Yes No


Current policy expiration date?

How would you prefer to be contacted?
	Email
	Phone
	Postal Mail
Any Additional Comments- Please list pets:

IMPORTANT Submitting this request form does not guarantee coverage. We will acknowledge your information request within one business day, and will advise you on your coverage options. Please check the button below before submitting this form.
*I understand that submitting this request form does not guarantee coverage.