Lee County Inside

Personal Home Quote
This form is a request for PERSONAL HOME insurance coverage. Please note that this form is for a REQUEST ONLY. By submitting this form it does not bind coverage in any way. If you do not hear from us in a reasonable amount of time, ASSUME WE DID NOT GET THIS REQUEST FOR AN INSURANCE QUOTE, and call our office.

I understand that filling out and submitting this form DOES NOT bind coverage in any way, and the only way coverage can be bound will be when I am informed of a binder or policy is issued by the agent representing me.

Full name, Address
E-Mail:
Phone:
Any claims in the last 5 years, if so, please describe. ***Please list any damage sustained by the hurricanes and what repairs are completed.
House Square feet, Number of full baths, Number of half baths	sq ft full half
Porch? Attached garage? If so, how many cars.	Sq. feet of deck or porch YES NO Number of Cars
Current dwelling coverage amount?

Number of families in the dwelling?
Have you had more than one claim in the last 5 years?		YES NO
What year was your home built?
Who lives in the dwelling?
Occupancy status?
Dwelling style?
If Mobile/Manufactured Name of Park
Heating and cooling system?
Exterior Walls?
Roof covering?
Foundation type?
Do you need flood insurance?
Do you have a swimming pool? Swimming Pool Style	YES NO
What is the plumbing type in your home?
Do you have a business on the premises?		YES NO
Have you had bankruptcy, foreclosure repossessions, judgment or charge off accounts in the last 5 years?		YES NO
Do you have a dog? What breed?		YES NO
Do you have more than two pets in your home?		YES NO
Do you have any livestock or exotic pets?		YES NO
Do you have a Trampoline?		YES NO
Do you have a wood, oil or kerosene stove?		YES NO
Is dwelling located within 1000 feet of a fire hydrant?		YES NO
Is dwelling located within 5 miles of a responding fire station?		YES NO

Sprinkler System?
Fire alarm type?
Burglar alarm type?
Do you have a fire extinguisher in the home?	YES NO
Do you have a smoke detector in the home?	YES NO
Do you have deadbolt locks?	YES NO
Is it a smoke-free household?	YES NO

Additional Information (e.g. Address of home to be insured if different from above):

390 Pondella Road Suite 1 * North Ft. Myers, FL 33903 * Phone: 239.656.5551 * Fax: 239.656.0640

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