Lipstone Insurance

Homeowners Insurance Quote Request

To receive your free, personalized homeowners insurance quote, please COMPLETE and SUBMIT the following questionnaire.

All information is received securely using SSL encryption, is kept fully confidential and is used for quoting purposes only.

By submitting this completed form you understand there is no coverage in force until an application is approved and premium is received by the insurance company. You certify that the statements made on this quote request are accurate to the best of your knowledge. This Web site should not be construed as a solicitation of any sort in any jurisdictions other than those in which the agency holds a license and is authorized to transact business. A list of licensing state(s) can be viewed at the bottom of our homepage.

1 - Your Contact Information

*Your Full Name:

*Your E-mail Address:

Occupation:

Current Address:

City:

State:

Zip:

Day Phone:

Evening Phone:

Best Way To Contact You:

How did you hear about our agency?:

If you were referred to us, please tell us by whom:

Due to some insurance company requirements, we request that you provide your Social Security Number. It has become increasingly common for insurance companies to use general credit scores in order to qualify policyholders for certain discounts and rate structures. Therefore, supplying this number increases our ability to prepare the most accurate quote possible.

Husband Social Security #:

Wife Social Security #:

I authorize the use of the above social security numbers to be used in the calculation of premium quotations with the agency's insurance companies.

To review a brief explanation about how insurance companies may use your
Social Security Number and General Credit Score...Click Here

2 - Current Homeowners Insurance Information

Insurance Company Name:

Policy Expiration:

If this is a new home purchase, when is your closing:

Purchase price:

Premium Amount:

Amount Currently Insured For:

Is your basic home policy:

Dwelling Amount:

Personal Liability Limit:

Medical Payments

Deductible

3 - Inform Us About Your Home

What Type Of Home Is This Quote For:

Address of home you are requesting for

City Where Home Is Located:

State Where Home Is Located:

Zip Code Where Home Is Located:

County Where Home Is Located:

Distance To Nearest Responding
Fire Station:

Distance To Nearest Fire Hydrant:

Fire district, if know:

How Long At Present Address:

Year Home Was Built:

Sq. Footage:
(excluding garage & basement)

sq. ft.

# of Claims In Last 5 Years:

Please provide dates, details & amount of loss:

Do you have a trampoline?

Yes No

Do you have a swimming pool?

Yes No

Do you have any pets?

Yes No

If yes, give type and breed:

4 - Protective Devices

Smoke detectors?

Yes No

Fire extinguishers?

Yes No

Alarm?

Deadbolt locks?

Yes No

5- Optional Questions

If you have a collection that is anything of value such as Coins, Stamps, Art, etc., specify the value of your collection:

If you have any furs or jewelry, please specify the approximate value/limits:

Do you have any special interests or hobbies that could be considered a home based business?

Yes No

Do you have/want backup of sewers and drain coverage?

Yes No

Click "Submit Request" to send your completed quote request.

One of our representatives will respond to you as soon as possible.
Thank you for giving us the opportunity to serve you.

Note: By submitting this completed form you understand that there is no coverage in force until an application is approved and premium is received by the insurance company. You certify that the statements made on this quote request are accurate to the best of your knowledge. This Web site should not be construed as a solicitation of any sort in any jurisdictions other than those in which the agency holds a license and is authorized to transact business. A list of licensing state(s) can be viewed at the bottom of our homepage.