Homeowners Insurance Quote Form

Welcome to Weber Insurance's Homeowners quote form.  To request a quote, please complete as much of the form as possible.  Use the Tab key to move from field to field.  If you leave the form, use the back button on your browser to return to the form.  This form will be emailed to us.  All information entered is confidential.

DO NOT USE THE "ENTER" KEY

USE THE "TAB" KEY  

OR YOUR MOUSE

TO MOVE FROM FIELD TO FIELD.
 
 

Tell me how to get in touch with you if I have additional questions:

 

Homeowner - 1

Homeowner - 2

Name
Date of Birth
SS # 
Home Phone
Work Phone
Cell Phone
Mailing Address
City
State  
Zip Code
E-mail
Send Quotes via

 CAUTION, IF YOU LEAVE THE FORM, USE THE BACK ARROW ON YOUR BROWSER TO RETURN.  ANY OTHER BUTTON WILL CLEAR THE FORM OF ALL DATA ENTERED.

Insurance Coverages

Expiration Date    

Current Insurance Company   
Dwelling Amount   
Personal Liability Amount   
Deductible Amount   

 

Ownership Information
Settlement Date   
Purchase Price   
Mortgage Balance   
Reason for wanting a quote   

 

Property to be insured

Address or MLS# 
City  
State    
Zip Code  
County and Township  

Size and Age of Home

Construction of Home  
Style of Home 

Number of Stories excluding basement

Basement  
What year was it built  

Approximate living area in  square feet, excluding  basement and garages
Central Air Conditioning  

Yes  No

Number of Bathrooms  
 Number of Fireplaces  
Garage type  
Number of cars  

Updates to Home

Roof type   Flat    Peaked
Roof last replaced  
Heat type  
Heater last replaced  
If oil heat, where is tank? 
Electrical system  
 Circuit breakers     Yes       No
Electric last updated  
Plumbing type  
Plumbing last updated  

How is the Home used

Number of families  occupying the home    
Occupancy    

               List Claims made in the last four years

Type of  claim    
Date of Claim  
Amount Paid by Insurance $  
Details of claim  

 

     Enter security features, other claims and your comments in the space provided below:

 

Name of person completing this form: 

Please contact me as soon as possible regarding this matter.

 
 
 Be patient, it will take some time for the information to be processed.  A Form Confirmation will be displayed.  Please review the information you entered.  If you need to correct any information, use the "Back" arrow on your browser to return to the form with the data you entered still in the form.  Clicking on "Return to the Form" will erase all data and return you to an empty form.

Are you ready to send this information? (type "YES")                

 
 
 
 

                    

 

Copyright © 1999 Applications For You. All rights reserved.
Revised: March 02, 2008 .