HOMEOWNERS INSURANCE REQUEST FORM (Pennsylvania)

Homeowners Insurance Quote Request Form

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