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 # 
Occupation
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:  
Other Structures Amount:  
Personal Property Amount:  
Loss of Use Amount:  
Personal Liability Amount:  
Medical Payments Amount:  
Deductible Amount:  

 

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

 

Property to be insured
Address of MLS#  
City  
State    
Zip Code  
County and Township  
Distance to Fire Hydrant  
Distance to Fire Station  

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  
Swimming Pool  
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")          

 
 
 
 

                    

 

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Revised: February 28, 2008 .