Petruzelo Insurance Agency, Inc. - Get A Quote - Homeowners, Renters & Condominiums Quote

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	Homeowners, Renters & Condominiums Quote

Note: Required fields are marked with an asterisk (*)

Personal Information Name*:
Current Address*:
City*:
State:
Zip*:

Home Phone*: - -

Work Phone: - -
E-mail*:

Date of Birth*:

Social Security #*: - -

Do you own or rent your home?:
How long at your present address*:

Prior Address*:
Prior City*:
Prior State*:
Prior Zip*:

Prior Address:
Prior City:
Prior State*:
Prior Zip:

Education Level:
How Did You Hear About Our Agency?:

Who*:

Other*:

Current Insurance Present Home Insurance Company:
If new purchase, purchase price:
Home Now Insured For:
Personal Liability:
Personal Property (Coverage C):
Deductible:
Date Home Insurance Expires:
Number of Claims in the Last 5 Years:
Explanation of Claims:
Sq. Footage of Home:
Year Home was Built:
Number of Family: 1 2 3 4 Other
Smoker :

Heating Oil Gas Electric Other:
Year Heating System Last Updated:
If Oil, Location of Tank: Outdoor Inground
Outdoor Above Ground
Indoors

Electrical Circuit Breakers Fuses
Year Electrical System Last Updated

Roof Asphalt Shingle Wood Shingle Tile or Slate Other:
Year Roof Was Updated:

Plumbing Year Plumbing Was Updated:

Structure Type 1 Story 1-1/2 Story 2 Story 3 Story Split Level Bi-Level

Outer Construction Wood Stucco Masonry Masonry Veneer Vinyl Aluminum

Foundation Basement Crawl Space Slab

Garage 1 Car 2 Car 3 Car 4 Car
Attached Detached Basement Built-In Car Port

Bathrooms Number of Full Bathrooms
Number of Half Bathrooms

Other Features Do you have smoke detectors?
Do you have deadbolts?
Do you have fire extinguishers?:
Security System?:

If Yes, Type?

If Yes, Fire?

If yes, Burglar?

Fireplace Number of Chimneys
Number of Hearths
Woodstove

Basement Finished?
Square Footage

Deck, Porch, Patio Deck Sq. Ft.
Open Porch Sq. Ft.
Enclosed Patio Sq. Ft.

Pool No Inground Aboveground
If Yes, do you have

Fence:
Locked Gate:
Slide:
Diving Board:

Trampoline Yes No

Pets Do you have pets?:
If Yes, Type:
(More than one type, please list)

Breed:
(More than one breed, please list)

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The submission of this form does not obligate you to purchase. This is for quoting purposes only and in no way provides, effects, or binds any insurance coverage.

We are licensed in the following states/provinces:
Connecticut, Maine, Massachusetts, New Hampshire, New York, Pennsylvania, Rhode Island, and Vermont

© 2009 Petruzelo Insurance Agency.   All rights reserved.
4 Research Parkway  | PO Box 5050  |  Wallingford, CT 06492-7550
Call Us Toll Free: 1-866-479-3327 | Fax: 203-269-7588
insure@petruzelo.com

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