NIA HOME | TRUCK | BUSINESS| HOME | HEALTH & LIFE | AUTO | INVESTMENTS | STAFF | REQUEST FORM | REQUEST A CERT


Home Owners Quote Request . . .

Please provide us with the information in this form below so we can calculate the best insurance premium for you.  Please call toll free 800-527-0808 if you have questions or need help.

We go the extra mile for you!

Owner Contact Information
Owner 1 Name   Date of Birth 
Owner 2 Name   Date of Birth 
Street Address
Mailing Address
City    State   ZIP
E-Mail Address
Day Phone
If the home is located in the country please provide section and Township information
Previous Address if
less then 3 years
Required Effective Date e.g 05/30/2007

Insurance Options
How many people live in the home
Requested Deductible
Would you like Earthquake Coverage? Yes   No
Do you operate a business out of the home? Yes   No  If Yes answer the next question
  What Type of Business? 
Do you have a computer on the property? Yes   No       If Yes: Estimated Computer Value $
Do you have a swimming pool? Yes   No        If Yes answer the next three questions ...
How High is the fence around the Swimming Pool?  e.g. 5 feet
Is there a diving board?  Yes   No
How Deep is the pool?    e.g. 5 feet
Do you have a Trampoline? Yes   No   NOTICE:  If yes, we are sorry but we are unable to quote you due to insurance guidelines with the companies we quote.
Have you had any
claims in the past 3 years?		 Yes   No  If Yes, Please use the field below to explain in detail the dates and costs
 
 

House Information

Year House was Built
Construction Style Wood Frame Brick  Other     If Other Explain: 
Does it Have a Fireplace Yes   No   If yes, please answer the next question
   What Type:  Masonry  Prefab  Insert  Other  
Auxiliary Heating? Yes   No  If yes please describe below
   Type of Auxiliary Heating: Wood Stove  Coal Furnace  Pellet  Solar  Other
Do You Have Smoke Detectors? Yes   No
If you were to look straight down on your house from above, what shape would you say your house is? Rectangle  Square T Shape U Shape   Other     if other, describe below
 Other:
House Style Ranch  Split Level  Other    If other, describe
Exterior Wall Covering Vinyl Siding   Aluminum Siding  Brick  Composition Lap   Other
   If other describe:
Roof Type Composition Shingles   Wood Shake  Metal    Other if other, describe below
   Other:
Basement   Yes   No     If yes answer the questions below
   Type:  if other, describe below
   Other: 
 Square Feet In Basement: 
   Is the Basement Finished:  Yes   No
   What Percentage of the Basement is Finished: %
Garage Yes   No    If yes please answer the questions below
  Garage Type: 
   How Many Cars Fit Inside: 
   Square Feet of Garage:    
Are there any attached structures Yes   No    If yes please check all that apply below
  Breezeway  Covered Porch  Deck  Enclosed Porch  Sunroom  Other
 If other describe:
Use the Field Below to List Square Footage of each Attached Structure:
 
Please use the field below to provide us with any other information you think is useful to creating an accurate quote for your property.