Hall-Green Agency, Inc.

Homeowner's Quote Request

Effective Date:

Your Name:

Your Mailing
Address:

Street

City & State Zip

E-mail Address:

Daytime Phone #:

Choose One:

Please call me with quote premium.
Please send quote via e-mail.

Current coverage:

Company: Expiration Date:

Type of policy desired:

Amount of insurance desired:

Homeowners only:
What is the value of your home?

Condo/Renters only:
What is the value of your personal property?
Liability Limit:

Medical Payments:

Valuation of Home:

Personal Property Valuation:
Deductible:

Property Information:

What is the construction type of your home?
In what year was your home built?

In what County/Township are you located?
Distance to the nearest fire hydrant?

What kind of pets do you have?
Do you have a swimming pool?
Yes No

Do you have a trampoline?
Yes No Do you use a wood burner?
Yes No

Smoke Detector(s) Installed
Home Security System Installed

Home Updates: Enter year updates were made. If year not known, enter "unknown":

Roof:

Wiring:
Plumbing:

Heating:

Optional Property Coverages:

Earthquake Coverage Requested
Flood Coverage Requested
Sewer/Water Backup Coverage Requested

Property Floaters - Indicate limits below:

Antiques: Coins: Computers: Fine Arts:	Furs: Jewelry: Stamps: Tools:
Other Floater Coverage: Limit of Insurance:

Previous Loss Information:
Please describe any losses or claims filed on your Homeowners Insurance in the last 3 years:

Date of loss: / Type of loss: / Amount of claim:

Additional Comments:
Please use the box below to enter any additional information you wish to include:

We cannot bind coverage from an email or voicemail request. Coverage is bound after you receive a written email or telephone confirmation from an agency staff member.

If you have not received a response from us within one business day, please contact us again.

Thank you.

Hall-Green Agency, Inc.
146 North Depeyster Street • Kent OH 44240
(330) 673-5873 • Fax: (330) 673-1350