Le Claire Insurance

J L Le Claire & Sons Insurance Agency

The Protection and Security you would expect from Family

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Home Quote

Homeowners Insurance Quote Request Complete the following information if you would like to obtain a quote. Please understand this is not an application. All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
Personal Information *Required
*Last Name
*First Name
*Street Address
*City
*State
*Zip Code
Phone Number
Fax Number
Social Security Number
*Birth Date
*Email Address
Property Information
*Property Street Address
*City
*State
*Zip Code
Number of Bedrooms
Number of Bathrooms
Number of Fireplaces
How many porches or decks are there?
What year was it built?
What date was the property purchased?
What is the construction type?
How many stories is it?
Total square footage
What foundation type?
If basement, is it finished	Yes No
Garage Description
How many car garage or carport
What type of roof covering?
Was the roof updated?	Yes No
If yes, what year?
Does the building have a pool?	Yes No
If yes, is it fenced?	Yes No
If there is a pool, is there a diving board?	Yes No
If there is a pool, is there a slide?	Yes No
What is the distance to fire protection?
Is the building in the brush?	Yes No
Is there a brush hazard within one mile of the building?	Yes No
If yes, has the brush been cleared by 250 feet from all sides of the building?	Yes No
Is there a smoke alarm?	Yes No
Is there a fire extinguisher?	Yes No
Are there deadbolts?	Yes No
Is the electrical updated?	Yes No
If yes, what year was electrical updated?
Are there circuit breakers?	Yes No
What is the service amperage? i.e. 60,100,200 amps
How old is the heating/ air conditioning?
Is the heating / air conditioning thermostatically controlled?	Yes No
What is the energy source?
What is the heating system?
What is the cooling system?
Has the plumbing been updated?	Yes No
If yes, what year was plumbing updated
Is the plumbing copper?	Yes No
Does the building have interior automatic fire sprinklers?	Yes No
Is there a theft alarm?	Yes No
What is the fire district?
*Are there dogs on the property?	Yes No
*If yes, how many and what is the breed of each dog?
*Are there any other pets or animals on the property?	Yes No
*If yes, how many and what is the description of each?
Current Coverage Information
Current Insurance Company
Expiration Date
Current Premium
Were there any losses or claims in the last 5 years?	Yes No
If yes, what is the date, amount paid and description of each loss or claim?
Desired Coverage Information
Dwelling Amount - Coverage A
Other Structures - Coverage B
Personal Property - Coverage C
Loss of Use - Coverage D
Premise Liability - Coverage E
Medical Payments - Coverage F
Policy Deductible
Do you want building replacement cost coverage?	Yes No
Do you want contents replacement cost coverage?	Yes No
Questions or Comments

Homeowners Insurance Quote Request

Personal Information

Property Information

Current Coverage Information

Desired Coverage Information