STEVE BALLINA AGENCY

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Homeowners and Renters Quote Form

Please fill out this form and receive a quote within 24 hours
Call (630) 548-4848 with any questions

* Indicates required field

Primary Insured Name *

First

Last

Phone Number *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Date of Birth *

Social Security Number *

Education Level *

Occupation *

Spouse's Information

If no spouse then skip to next section

Spouse Name *

Spouse Date of Birth *

Spouse Social Security Number *

Spouse Education Level *

Spouse Occupation *

Home Information

Number of Residents Living in Home *

Occupancy *

Owner Occupied Renter Both

Number of Family Living Units in the Same Building *

Number of Bathrooms *

Square Footage *

Number of Stories *

Basement *

Yes No

If yes, is it finished? *

Yes No

Year Built *

Please state the year each of the following were updated. If unknown, simply write "unknown"

Roof *

HVAC *

Electrical *

Plumbing *

Attached Garage *

Yes No

Garage Size *

Exterior Walls *

Brick Stone Siding

If siding, what type? *

Number of Fireplaces *

Pool *

Yes No

Trampoline *

Yes No

Do you own a dog? *

Yes No

If yes, what breed? *

Monitored Burglar or Fire Alarm *

Yes No

Years Owned *

Email your declaration pages to steve.sbagency@gmail.com or complete the following:

Contents Coverage Desired *

Current Building Coverage *

Current Liability Coverage *

Current Insurance Company *

Number of Years with this Company *

Expiration Date *

Any other information you feel would be valuable *

Submit

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