Archer A. Associates, Inc. - Insurance Agents and Brokers
Homeowners Quote
Policy Holder
Contact Name *
Email
Phone Number
### - ### - #### 
Property Location
Address *
Street Address
Address Line 2
City State / Province / Region
Postal / Zip Code

Country

Current Insurance Information
Company Name
Current Annual Premium
Expiration Date
MM / DD / YYYY  
Deductible Desired
Amount of Liability
Earthquake Coverage Desired? *
Yes
No
Have you filed for bankruptcy within the past 7 years? *
Yes
No
Dwelling Information
Estimated Replacement Cost *
Square Footage *
Years Constructed *
How Many Floors?
1 Story
1.5 Story
2 Story
Bi-Level
Tri-Level
Type of Construction
Wood, Stucco, Masonry, Brick Veneer, Aluminum Siding, Other
Other Features
Dead Bolts
Smoke Detectors
Fire Extinguisher
Central Station Fire Alarm
Central Station Burglar Alarm
Home Located within 5 miles of Fire Station
Home Located within 1000 feet of a Fire Hydrant
Swimming Pool
Trampoline
Home located within City Limits
Claim 1

Include the date of the claim, amount paid, claim type, and a description of the claim.
Claim 2

Include the date of the claim, amount paid, claim type, and a description of the claim.
Claim 3

Include the date of the claim, amount paid, claim type, and a description of the claim.
Personal Property
Jewlery & Watches
Furs
Silver
Firearms
Stamp & Coin Collections
Fine Arts & Breakable Items
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