Paul & Dixon Insurance Agency

Homeowners Quote

Your Name

First

Last

Your Contact Information

Address

City

State

Zip Code

Preferred Phone

Alternate Phone

E-mail Address

Current Policy Information

Do you currently have
homeowners insurance?

Yes

Current Company

Exp. Date of Policy

Own or rent

Please choose the category that applies to you:

Current Policy Information

Current Insurance Value

Year Built

Construction Type

Please indicate recent
updates (past five years)
if your home is over
20 years old

Plumbing

Electrical

Heating

Roof

Deductible for
Property Coverage

Personal Liability Limit

Own animal(s)?

Alarm Systems?

Yes

Within two miles of ocean?

Yes

Smoke detectors?

Yes

Within 5 miles of fire station?

Yes

Would you be interested in
combining your insurance with
your auto insurance for
additional discounts?

Yes

Do you have more than $2000
worth of jewelry, silver,
or collectibles?

Yes

Rental Policy Information

Estimate the cost to replace
your personal items:

What deductible would
you prefer?

What personal liability
limits would you prefer:

Do you have more than $2000
worth of jewelry, silver,
or collectibles?

Yes

Condo Policy Information

Name of Complex

Assocation Name

Fax

Phone

Size of Unit

Do you currently have insurance?

Yes

Insurance Company Name

Policy Exp. Date

Estimate the cost to replace
your personal items:

What deductible would
you prefer?

What personal liability
limits would you prefer:

Do you have more than $2000
worth of jewelry, silver,
or collectibles?

Yes

© 2009 Paul & Dixon Insurance Agency, LLP. 388 County Street, New Bedford, MA 02740. Phone: 508-966-8593 Toll-Free (MA only): 800-785-8593.
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