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For HomeOwners, Fire Insurance, or Landlords
REQUIRED INFORMATION FOR INSURANCE QUOTE

Thank you for selecting Spiridon Insurance Group for a Quick Home Owners, Fire Insurance, or Landlords Insurance Quote.
Our goal is to provide our valued clients with a superior insurance policy at the most economical price.
Spiridon provides their clients with "Peace of Mind" because they have the right protection.

If you prefer, please complete the Information Sheet and fax to us.

First Name:		Last Name:*
Date of Birth:		Social Security Number:
Joint Owner Last Name:		Joint Owner Last Name:
Date of Birth:		Social Security Number:
Street Address:*		City:
State:		Zip:*
Phone*:		Alternate Phone:
Marital Status:	Single Married	How may we contact you? Telephone email
Does anyone else live with you?	Yes No	e-mail:

Additional Occupant First Name:		Last Name:
Date of Birth:		Social Security Number:
Additional Occupant First Name:		Last Name:
Date of Birth:		Social Security Number:
Is anyone over 55 retired?	Yes No
Date you moved in (Month/Year)		If less than 2 years, list previous address:
Total Square Footage:		Number of stories:
Basement:	Yes No	Percentage % completed
Central Air:	Yes No	Fireplace:	Yes No	Number of Fireplaces:
What fire department services your area?
Deck or Patio:	Yes No	How large:
Full Baths:		Half Baths:
Inground Pool:	Yes No	Satellite Dish:			Yes No
Garage or carport:		Garage-type: (built-in has living space above)
Bedrooms:
Year purchased:		Year Built:
Roof Regular Shingle:	Yes No	If not shingle, list composition:
Current Market value:
If home is over 15 years old, check if renovated:	Roof Electrical	Plumbing Heating/Cooling
Smoke Detector:	Yes No	Deadbolts:			Yes No
Fire Extinguishers:	Yes No	Monitored Alarm System:			Yes No

Currrent Insurance Company:
How long have you been with them?
Current Premium:
Have you had a lapse in coverage in the past 5 years?		Yes No
Which deductible option are you interested in?
Would you like ID Theft Coverage?		Yes No
Any property insurance losses in the past 5 years?			Yes No
When were the losses?
List type(s) of loss:
Do you have any special coverage needs such as scheduled jewelry, guns, silverware:		Yes No
Special Coverage Item:	Special Coverage Amount:
Special Coverage Item:	Special Coverage Amount:
Special Coverage Item:	Special Coverage Amount:
Special Coverage Item:	Special Coverage Amount:
Mortgage Company:
For a new house, complete the following:	Closing Attorney:
Closing Date:	Contact Number:
We can provide you with a multi-line discount by insuring your auto(s). Do you want your proposal to include home and auto discounts?		Yes No

Special comments or questions:

*denotes required field

CALL TOLL FREE 1-877-774-7436