Homeowners Quote Form

For a Homeowners, Condominium or Renters insurance quotation for any state in New England, please fill out the following form and click the submit button. An agent will contact you to review a personalized quotation within 24 hours. If you have any questions about this form or about coverage in general, please contact us.

Name:

Address (city, state, zip code):

E-mail:

Telephone:

Fax:

Best time to call:

Type of policy (homeowners, condo, renters):

Effective date of coverage:

Location of residence (if different from above):

Is this a Primary or Secondary residence:

Approximate year of construction:

Construction type:

Any losses in the last 3 years:

Number of families:

Value of home, or amount of current insurance:

Personal property amount
(condo and renters only):

Personal Liability (each occurrence):

Deductible:

Replacement cost options
(check all that apply):

Dwelling: Contents:

Protective devices
(check all that apply):

Smoke detectors:		Dead bolt locks:
Fire extinguisher:		Non-smoker:
Central Station Burglar Alarm:		Central Station Fire Alarm:
Police Station Direct Alarm:		Fire Station Direct Alarm:
Automatic Sprinklers:

Earthquake Coverage:

Flood Coverage:

Scheduled Property
(enter an amount for all that apply):

Jewelry:	vaulted?	Fine Arts:
Golf Equipment:		Silverware:
Cameras:		Furs:
Musical Instruments:		Guns:

Comments or additional pertinent information:

Submitting an insurance quotation request to Ellis Insurance Agency does not constitute a binding confirmation of new or altered insurance coverage. Verbal or written confirmation must be obtained from Ellis Insurance Agency to confirm binding or altering coverage.