Homeowner Insurance

Please completely fill out the form below so that we may provide you with an accurate homeowners insurance quote.

Name:

Email:

Daytime Phone:

Property Location:

Zip Code of Property:

Year Built:

Total Living Area:

Number of Families:

Style of House:

Number of Stories:

Foundation:

Exterior Walls:

Roofing:

Please choose all that apply:

Attached Structures
	Porch
	Deck
	Patio
	Fireplace
	Chimney
	Enclosed Porch

Interior Items
	Hardwood Floors
	Wall to Wall Carpet
	Ceramic Tiles

Have you had any claims or losses in the last 5 years on a homeowners, condominium, or tenants insurance policy?
Yes
No

If yes, please give the details of the claim(s) and how much was paid out.

Do you have any of the following in your house or on your property?
	Swimming Pool
	Trampoline
	Wood Burning Stove

Any Pets?
Yes
No

If yes, please describe what type and breed.

Current Homeowners
What is your home currently insured for?
(building/dwelling)

A New Home Purchase?
What is your settlement date?
What is the purchase price?
What is your mortgage amount?

Please check any of the following that are in your home which could allow you to be eligible for discounts:

	Smoke Detectors
	Dead Bolt Locks
	Fire Extinguishers
	Sprinkler System
	Central Station Burglar and Fire Alarm

Personal Liability Limit:
Deductible:

Water Backup of Sewer and Drain?
Yes
No

In order to determine possible homeowners insurance eligibility, we will be required to run an insurance score. Please fill out the following information so that we may order theis report:

Your current address:
Spouse/Partner Information

Name:

Use this section below for comments, questions, or any other important information that would factor into the quote we will offer. Please include any jewelry, watches, furs, fine arts, or any other high value items and/or collectibles you may want scheduled on your homeowners insurance.

By clicking the submit button below, you are sending a quote request with your personal information to the CrossKeys Insurance, Inc. This information will be used solely to quote your automobile insurance needs. No coverage will be issued or bound by this quote request. The information given above will initially determine company eligibility, however more information and driver history reports may be required to verify eligibility for any quote.

You may be eligible for a discount on your homeowners if we also insure your automobile insurance. Please feel free to send a quote request for automobile insurance as well on the automobile insurance page.