Homeowner’s Quote Questionnaire Step 1 of 4 25% Date of Birth: Date Format: MM slash DD slash YYYY Today's Date: Date Format: MM slash DD slash YYYY Effective Date of Policy: Date Format: MM slash DD slash YYYY Purchase Date/Time at Present Address: Date Format: MM slash DD slash YYYY Name: First Last Marital Status:MarriedSingleDivorcedWidowedSpouse’s Name/2nd Insured’s Name First Last Current Insurance Carrier:Email: Address: Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Expiration Date: Date Format: MM slash DD slash YYYY Reason for Request:PricingUnsatisfied With Agent/CarrierCarrier Not Offering a RenewalPlease share how you heard about Fox Insurance:Please let us know who, if so, you have been working with at Fox Insurance:Phone (Home):Phone (Work/Cell):Employer:Spouse' Employer:Date of Birth: Date Format: MM slash DD slash YYYY Social Security Number:Spouses' Date of Birth: Date Format: MM slash DD slash YYYY Spouses' Social Security Number:Mortgage:YesNoHave there been any losses in the last 5 years?Please list date and description. Age of Dwelling:Renovation Years of:Wiring:Plumbing:Heat/Cooling:Roof Material:Composition ShingleWoodTileMetalOtherYear of Roof:Construction Type:FrameBrickOtherExterior Walls:Heating/Cooling System Type:Number of Stories:Square Footage:Single Family Dwelling:YesNoInside City Limits:YesNoFoundation:BasementCrawlspaceSlabResponding Fire Department:Distance to Station:Distance to Hydrant (Ft):Number of Bathrooms:Porch/Deck (list type & size):Fireplace or Wood Stove:NoneWood Burning FireplaceGas FireplaceStanding Wood StoveGarages:AttachedDetachedNoneCarport:YesNo Any Special Features, or Built-in Terms?Home Under Construction:YesNoAny Business or Farming Practices conducted on Property? Please explain:Any trampoline/swimming pools/hot tubs/spas/etc.?Any animals on property? (list animal type & number; if dogs, include the breed):Does Anyone Smoke:YesNoSmoke Alarm:YesNoDeadbolt Locks:YesNoAlarm System:NoneDirect AlarmCentral Station Alarm Preferred Deductible:Any items (Jewelry/furs), or collections to schedule?YesNoCoverages Desired Dwelling:Personal Property:Liability:Medical Payments:Post ImageWhich method of communication do you prefer for one of our agents to reach out to you?PhoneEmailAppointment in person Share this: Click to share on Facebook (Opens in new window) Facebook Click to share on X (Opens in new window) X Click to share on LinkedIn (Opens in new window) LinkedIn Click to share on Reddit (Opens in new window) Reddit Click to email a link to a friend (Opens in new window) Email Click to print (Opens in new window) Print