Homeowners Insurance Quote Form

-About The Agency
-A Professional Agency

with Personal Service

-Who We Are

      -Homeowners
      -Automobile
      -Umbrella Liability
      -Boats / Yachts
      -Motorcycles

      -Homeowners FAQ's
      -Auto FAQ's
      -Business FAQ's
      -Financial FAQ's

    127 Norwich Road
    P.O. Box 405
    Central Village, CT 06332

    Phone: (860) 564-3315
    1-800-292-1127
    Fax: (860) 564-8253

Please, residents of CT only.

Name:

E-mail:

Website

Phone Numbers:

  Daytime:

  Evening:

  Fax:

How would you prefer to be contacted regarding your quote? Phone Fax Mail E-mail

If you would prefer to be contacted by phone, please let us know the best time to call.

Address:

City:

State: Zip:

Structural Information

What is the style of your home?
How many stories is your home?
What is the total square footage of the ground floor of your home?

Do you have any of the following?

Swimming Pool	Yes No
Is it fenced?	Yes No
Trampoline?	Yes No
Burglar Alarm
Sprinkler System
Kerosene, wood or oil stove?	Yes No
Dog?	Yes No
Breed:
Computer?	Yes No
Livestock?	Yes No
How many?
Type:
Unusual/exotic pets?	Yes No
Type:

Is your home located

Within 1000 feet of a fire hydrant?	Yes No
Within 5 miles of a fire station?	Yes No
Close to a body of water or susceptible to flooding?	Yes No

General Questions

Year home was built:
Is business conducted on the premises?	Yes No
Type?
Does anyone in your home smoke?	Yes No
Did you experience any loss or claims in the last 5 years?	Yes No
What is the Expiration Date of your current insurance?

Protective Devices

Smoke detectors?	Yes No
Fire extinguishers?	Yes No
Fire alarm?
Dead bolt locks?	Yes No

Additional Information

Senior citizen discount (all occupants age 55 or above):

Yes No

Homeowners Coverages and Deductibles

Dwelling (Coverage A):
Personal Liability Limit:
Desired deductible:

Optional Data

Quote requested within:	24 hours 48 hours 72 hours 120 hours
Do you want an umbrella quote:

Optional Questions

If you have a collection that is anything of value such as Coins, Stamps, Art etc... specify the value of your collection:	$

If you have any furs or jewelry, please specify the approximate value/limits:	$

Do you have any special interest of hobbies that could be considered a home based business?	Yes No

Please note:
Quintal Agency only services residents and businesses in the state of CT.