NHC Insurance Services: Customer Service - Quotes

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Customer Service: Quotes - Homeowner's Quote Request
IMPORTANT! Please Read Before Completing. By completing and submitting this form you agree that no coverage is bound and no policy is in effect until you are contacted by one of our representatives. All sections in bold and red are required.

HOMEOWNER'S POLICY QUOTE REQUEST
YOUR PERSONAL DATA
Name:
Current Address:
City:
State:	California
Zip Code:
Social Security #:
E-Mail:
Home Phone:
Work Phone:
Cell Phone:
Fax (optional):
Employer:
Occupation:
Years on job:
Birthdate:
How were you referred to NHC:

Marital Status:	Single Married
if married, please enter spouse information below
Spouse Name:
Spouse Soc. Sec. #:
Spouse Employer:
Spouse Occupation:
Spouse Years on Job:
Spouse Birthdate:
CURRENT POLICY INFORMATION
Current carrier:
Policy #:
Coverage amount:
BUILDING INFORMATION
Location Address:
City:
State:	California
Zip Code:
Year built:
Square feet:
# of stories:
# of bathrooms:
# of fireplaces:
# of chimneys:
Built on slab:	Yes No

Copper plumbing:	Yes No
Year plumbing last updated:

Circuit breakers:	Yes No
Year electrical last updated:

Heating vents/registers:	Wall Floor Other
Heating type:	Gas Electric
Heating system:	Forced air Other
Heating; year installed or last updated:
Air conditioning:	Yes No

Roof type:
Year roof last updated:

Garage:	None Attached	Detached Carport
If so, # of spaces:

Porches/Breezeways:	Yes No
If so, how many:
If so, square feet:
If so, open or enclosed:	Open Enclosed

Do you have dogs:	Yes No
If so, how many:
If so, what kind:
If so, any claims:	Yes No

Do you have a pool:	Yes No
If so, is it fenced:	Yes No
If so, diving board:	Yes No

Are you in escrow:	Yes No
If so, closing date:
If so, purchase price:
SUPPLEMENTAL INFORMATION
Is there a centrally monitored fire/burglar alarm system:
Yes No
If so, what company monitors it (please include company phone number):


Do you have a home based business:
Yes No
If so, what is the nature of this business:

If so, do you have clients come to your home:
Yes No
If so, do you keep inventory in your home:
Yes No

Do you have any employees:
Yes No
If so, what are their positions:

If so, how many hours a week do they work:


Has your home been remodeled:
Yes No
If so, what was done:

If so, was square footage added:

If so, what was the cost to remodel:


Is this going to be your primary residence:
Yes No
If not, please advise residence use:
Secondary Residence Vacation Home Rental Property
CLAIMS
In the past five (5) years have you had any prior insurance losses such as fire, earthquake, water damage or dog bite claims? if so, please give date and describe below. (It doesn't matter whether or not your insurance company paid any money).

SUBMIT QUOTE REQUEST
Send my quotation via:	E-Mail Fax	Postal Mail Phone

We value your input as PRIVATE information. Every step has been taken to insure your privacy. Our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy. Yes, I agree.

Some companies require us to run a CREDIT SCORE to help qualify you for payment options. By checking the box below you grant us permission to run your credit score. Yes, check my credit.

Please review the information you have entered above carefully. When you are ready to send your data, click the button below. Please click only once. You should receive a response back from one of our highly qualified agents within 1-2 business days.