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HOMEOWNER QUOTE
(Washington & Oregon residents only, please.)

Please provide us with the following information regarding your home. For an accurate rate quotation it is necessary to estimate the replacement cost of your home first, in order to determine the amount of coverage you need.

Our homeowner policies include these special features:

	HOME REPLACEMENT GUARANTEE
	PERSONAL PROPERTY REPLACEMENT
	ADDITIONAL LIVING EXPENSES
	PERSONAL LIABILITY
	PERSONAL INJURY
	COVERAGE FOR DETACHED STRUCTURES
	EARTHQUAKE COVERAGE FOR QUALIFYING HOMES (EXTRA COST)
	HOME BUSINESS (EXTRA COST)

First we need some information about you: (If you've already provided this information, please just enter your name below. Thank you.) (Also, if you have any questions about any part of this form, please call us at 1-888-271-5663).
Name:
Address:
City, St. Zip
Date of Birth
Social Security #
Your Phone & Fax:
Your E-Mail Address:

Property Information:
YEAR BUILT
CONSTRUCTION MATERIAL
TYPE OF CONSTRUCTION
TOTAL LIVING AREA	Sq. Feet
BASEMENT	Sq. Feet
BASEMENT Finished?	Yes No
GARAGE
DECK	Yes No
DECK	Sq. Feet
# of BATHROOMS
# of FIREPLACES
ROOF MATERIAL
In the past three years have you had any losses involving your home or personal property?	Yes No If yes, details...
Current Insurance Company:
Do you have any comments or questions for us?
SEND MY QUOTE VIA

Thank you very much for requesting a quote from
E-Z-INSURANCE.COM.

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