Homeowners Insurance
Quote Request Form

Pennsylvania
For other states

To receive a quote, please fill out the form below....


Name:        Social Security #: 
Address:
City, St., Zip:    
Phone Number:
E-Mail Address:
Your Birthdate:
You are a:  This is a 

Current Insurance Information
Insurance Company:  Expiration Date: 


Your Current Coverages
Dwelling Amount Other Structures Contents Liability Limit Medical Payments

Any property that should be schedule, due to its value....
Jewelry:
Furs:
Silverware:
Golf Equipment:
Cameras:
Fine Arts:
Amateur Musical Instruments:
Stamp Collections:
Coin Collections:
Type of Dwelling: Property Deductible Year Built Construction
Updates to Home:
Furnace Year: 
Plumbing Year: 
Roof Year: 
Electrical

Wire Type: 
Fuse Type: 

Year: 

Any other coverages, comments and any additional information....

PROTECTION (Check all that apply).....
Smoke Detectors?  Extinguishers:  Burglar/Fire Alarm: 
connected to central station
Dead Bolts: 

GENERAL QUESTIONS

Do you have a wood burner stove?
Yes
No
      If YES, was it professionally installed?
Yes
No
Do you operate a business from your home?
Yes
No
If YES, Type of Business:
Have you ever filed for bankruptcy?
Yes
No
Do you have a trampoline?
Yes
No

CLAIMS INFORMATION...

DATE WHAT HAPPENED AMOUNT PAID


Home Page

E-Mail
M c G R A T H   I N S U R A N C E   G R O U P

4170 William Penn Highway, Murrysville, PA. 15668-1890
(724) 327-8474                  (FAX) 327-7911
Toll Free: 1-800-977-2999               (FAX) 1-888-800-0034