Heritage Oaks Insurance

Other Home Services

Homeowner’s Quote Request Form

(please complete and hit “submit” button at bottom of the page)

*If you have any questions before you submit give us a call.*

Contact Info:

Name (First/Middle/Last):

Current Address:

City: State: Zip:

How long have you been at your current residence?:

Phone Number:

Email Address:

DOB (MM/DD/YY)

Subject Property:

Note: If the subject property is the same as your current address please type “Same” in in the Address bar

Subject Address:

City: State: Zip:

Purchase Price/Current Coverage:

Estimated Closing date (New Purchase only):

Underwriting Questions

Year Home was Built:	Square Footage:
Type of Roof:	Year Roof Was Replaced:
Number of Stories:	Number of Fireplaces:
Number of Garage Stalls:

Select Occupancy Type:

Select One:

Primary Residence

Secondary/Vacation

Rental

Single Detached Family Home

Condominium Town Home

Select Construction Type:

Select Foundation Type

4 Sided Brick

Masonry Veneer (Brick On Less than 4 Sides)

Stucco

Hardyplank

Frame (Siding)

Concrete Slab

Concrete Perimeter

Wood Posts

Other

Pool:	Yes No
If Yes, is pool/yard Fenced:	Yes No
Diving Board or Pool Slide:	Yes No
Trampoline:	Yes No
Fire Hydrant within 1,000 Feet:	Yes No
Fire Dept within 5 miles:	Yes No
Brush or Forest within 400 feet:	Yes No
Burglar Alarm:	Yes No
Business/Childcare:	Yes No
Pets:	Yes No
If Yes, What Breed and How Many:

Any claims in the past 3 years? Yes No
If yes, Please describe:

Any other comments or questions please feel free to leave us a message below:

How did you hear about us:

Mailing With Website	Craig's List
Call With Website	Newspaper
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