Get a Homeowners Insurance Quote All services offered by Selected Benefits are provided at NO cost to you. Please fill in ALL fields so that we may give you the best recommendation possible.

Primarily Insured Your Name   Date of Birth    Sex - Select - Male Female Home Address     City   State    Zip Contact Phone Number   Email Address*

Spouse Information Spouse Name   Date of Birth    Sex - Select - Male Female Used tobacco products in the last 12 months? Yes No - If yes, who? Applicant Spouse

Coverage Information Current Carrier?   Rental/Closing Date? Alarm? If so, who monitors? Yes No - If yes, who? Do you have Flood Insurance? Yes No Any Home/Renter's Insurance Claims in last 3 years? Yes No

Property Information Type of Construction? (Wood, Brick, etc) Number of Stories?   Gargage Type? - Select - Attached Detached Year Built?   How many Square Feet? Number of Fireplaces?   Number of Bathrooms? Roof Type? Age of Roof?   Do you have a Porch? Yes No Do you have a Breezeway? Yes No   Do you have a Deck? Yes No Purchase Price?   Loan Amount Remaining?  *I would like my insurance quotes sent to me via email. I understand that Selected Benefits will periodically re-email these quotes and that if I become a client, I will periodically receive email notification of benefit changes, rate increases, rate decreases and other pertinent information concerning my policy, etc. REV 10/03