INSURANCE MADE EASY�

COVER YOUR WORLD

Allen/Freeman/McDonnell Agency

will be happy to quote your

HOMEOWNERS INSURANCE.

Be advised that we are only licensed to provide insurance in Maine and New Hampshire. Please answer each question that follows and then send the form to us over the net. We will try to contact you within 24-hours. Thanks for considering

Allen/Freeman/McDonnell Agency.

Your Information:

Name*
Address*
City*	State*	Zip*
Birthdate

Address of Home to Be Insured:

Please check here is this is the same address as above.
Address
City	State	Zip
County*

Please supply Contact Information.
(All Requests will be answered by E-mail)

Day Time Phone Number:
Evening Phone Number:
E-mail:*

Current Insurance Information ( if any )

Current Insurance Carrier:
Expiration Date:

If you are purchasing a home, please answer the following two questions.

Purchase Price of Home?
Total Amount of Mortgage?
Would you like Mortgage Protection Insurance?		More information will be required and can been found on the Mortage Protection Page.

How much coverage do you want?

Dwelling*
Personal Liability*
Deductible*
Is this quote for a new home purchase?*		If yes, when is your Closing Date?

Rating Questions (please fill in as much information as possible)

Policy Type*
Dwelling Type*
# of Units?*	# of Stories*
Year Built*(approx.)	Square Feet	(if known)
Construction*	Foundation*
Type of Roof*	Last Replaced	(if known)
Plumbing*	Last Update	(if known)
Electrical System*	Last Update	(if known)
Heating*	Last Update	(if known)
If Oil Heat, Location of Tank*
Fire hydrant within 1000 ft*
Fire Station within 5 miles*
Central and/or Smoke Alarms*
Garage*
Swimming Pool?*	Diving Board or Slide?
Prior Losses Past 5 Years?*
Bankruptcy within 5yrs?*
Everyone in House a NON-SMOKER?*
Do you have a Dog?*	If Yes, What Breed?
How Did You Hear About Us?*

Thank you for considering Allen/Freeman/McDonnell Insurance Agency

NOTICE: Please be advised that insurance coverage cannot be changed or bound by submitting or leaving an electronic message or voice mail message. Allen/Freeman/McDonnell Agency or its parent company, Insurance Made Easy, Inc. does not resell or distribute your personal information in any form. We use the information from this form exclusively to try to provide you the insurance coverages which you are requesting. In completing this form, you give us premission to telephone you, if needed.

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