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Homeowner's Quote    
 
Styer Insurance Agency Inc.

Homeowner's Insurance Quote

For a competitive homeowners quote please complete and submit the information requested below.
 

Please fill out the form below as completely as possible.
Name:

Street address:
City:
State:
 Zip:
Township:
Phone:
Email:
Year of Home:
Style of Home:
# of Floors:
Square Footage:
Fire Hydrants Within 1000':
 Yes No
Approx. Distance to
Fire Department:
Desired Coverages
Dwelling Amount:
Other Structures:
Personal Property:
Loss of Use:
Personal Liability:
Medical Payments:
 
List Any Additional Coverages:
( ex: jewelry, collectables, musical instruments, etc.)
Current Insurance Information
Current Insurance Company:
Current Effective Date:
Property Updates
Roof Replaced:
Date Heating Updated:
Date Electrical Updated:
Fuses:
 Yes No
Circuit Breakers:
 Yes No
Have there been any claims filed on any property in the past 5 years?
Yes No
If Yes,
Date:
 
Description
of Claim:
 
Amount Paid:
Other Information
Do you own any pets?
Yes No
 

Type of Pet:
 

Breed of Pet:

Do you have a swimming pool? Yes No

Do you have a trampoline? Yes No

 
As part of the application process, we will order credit, motor vehicle and prior loss reports. This information will be used to evaluate your application. You may request a written statement describing our use of credit histories or insurance scores contained within our Credit Brochure. By submitting this quote will confirm for me that you are authorized to initiate this insurance transaction and obtain consumer reports on behalf of yourself and your spouse, if applicable, or other individuals who will be insured under the policy.