Adcock-Adcock Insurance - Homeowners Insurance Quote

Please complete this form in its entirety and click the 'Submit' button. An Adcock-Adcock Insurance Agency representative will then contact you regarding your Homeowners Insurance (HO-3) quote.

Remember that all of the information on this form is important for an accurate quote, so please don't skip any part of the form.

Completion of this form does not bind coverage

Contact Information
Name
Address
City		Zip
Phone	H			W
E-mail Address
Preferred Contact Method	E-mail Home Phone Work Phone

Property Location
Property Address
Property City		Property Zip
County		Inside City Limits?		Yes No
Fire Hydrant less than 1000' to home?	Yes No
Fire Department less than 5 miles?	Yes No

Property Description
Dwelling Amount	(Cost to reconstruct dwelling at today's cost.)
Year Built
Total Square Feet
Living Area Square Feet	(Excluding non air-conditioned areas such as garage).
Is this a new purchase?	Yes No
House In Gated Community?	Yes No
Construction Type	If mixed, % block
Number of Stories
Other Structures	Carport Attached Garage Detached Garage
Foundation
Fireplace?	Yes No
Alarm monitored by an outside service?	Yes No	Fire		Burglary
Trampoline?	Yes No
Pool	Above ground In ground		Screened Slide/Diving board
Fenced yard?	Yes No
Any business conducted on premises?	Yes Type:
	No

Pet Information
Number of pets	Breed (describe if mixed)
Describe any biting incidents
Any Farm Animals?	Yes No

Underwriting/Coverage Limit Information
Describe claims if any in last 5 years	Date Type Paid $
	Date Type Paid $
Personal Bankruptcy, Repossessions, Judgements, or Credit Problems in past 5 years?	Yes No
Roof Type
If home is over 30 years old describe age and updates of roof and heat, air, and electrical systems

Special Requests/Comments