Home Owners Insurance Quote Name First Last Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code CountyEmail Home PhoneWork PhoneDate of Birth MM slash DD slash YYYY Marital Status Single Married Spouse's Name First Last Type of Home 1 Story 1.5 Story 2 Story Tri-Level Quad Level Other Type of Construction Frame Brick Stucco Other Type of Siding Aluminum Steel Other Current Dwelling CoverageIf new homeowner, leave blank.DeductibleIf new homeowner, leave blank.Year BuiltTotal Square FeetMain Floor Square FeetBasement Finished Unfinished None Garage Unattached Attached None Holds how many vehicles? 1 2 3 Other Porch Yes No Type of Porch Covered Uncovered Size of PorchDeck Yes No Type of DeckSize of DeckCentral Air Yes No Type of Heat Natural Gas Electric L.P. Gas Oil Wood Heat – Year UpdatedFireplace Yes No How Many Fireplaces?What type of fireplaces? (select all that apply) Gas Wood burning Other Explain other type of fireplaceNumber of Bathrooms 1 1.5 1.75 2 3 Other Plumbing – Year UpdatedRoof TypeRoof – Year UpdatedElectrical Fuses Circuit Breaker AmpsElectrical – Year UpdatedValue of Personal PropertyMiles for Fire DepartmentRecreation Vehicles Boat Snowmobile 4-Wheelers If you have any items of special value (jewelry, silverware, guns, antiques, fine arts, collectibles) that you would like insured, please list hereAre any business or professionals conducted on the premises? Yes No If yes, please describeIs any buisness property kept on the premises? Yes No If yes, please describeLoss History InformationDate MM slash DD slash YYYY Type of LossAmountAdd a second loss? yes no Date MM slash DD slash YYYY Type of LossAmountAdd a third loss? yes no Date MM slash DD slash YYYY Type of LossAmountPlease remember by submitting an application for a quote does not provide or bind coverage. Be advised by submitting your application, you agree to receive a phone call from our office for some additional personal information to give the best quote options Citizens Ins. Agency has to offer. PhoneThis field is for validation purposes and should be left unchanged. Δ