Homeowners Quote Form

Property Type Required Property Type is required.	select Single Family Home Apartment Duplex Condominium Townhome Mobile Home
Approximate year built? Required Approximate year built? is required.
Do you live at this property? Required Do you live at this property? is required.	select Yes No
ZIP / Postal Code Required Input Required Please enter a valid Postal code.

Property Address Required Property Address is required.
Property apt/unit Optional
City Required Input Required
State Required Input Required	select DE NJ PA
Tell us about the place.
Construction Type Required Construction Type is required.	select Aluminum or Vinyl Mostly Brick Mostly Wood Frame Stucco Cinder Block Mostly Stone Veneer Log Other
Foundation Required Foundation Required	select Bsmt Fully Finished Bsmt 1/2 Finished Bsmt Unfinished Crawl Space Slab Other
Roof Type Required Roof Type is required.	select Asphalt Shingle Wood Shingle Tile Concrete Other
Roof Age Required Undefined	select 1-5 Years 6-10 Years 11+ Years
Primary heating system Required Undefined	select Gas (Forced Air) Electric Hot Water/Steam Radiator Oil/Coal/Kerosene Propane Stove
Wiring Type Required Undefined	select Copper Aluminum Knob and Tube
Number of Bedrooms? Required Number of Bedrooms? is required.	select 1 2 3 4 5 6+
Bathrooms Required Bathrooms is required.	select 1 2 3 4 5 6+
Number of Stories Required Number of Stories is required.	select One Story Bi Level Two Story Tri Level Other
Garage Type Required Garage Type is required.	select Attached - 1 Car Attached - 2 Car Attached - 3 Car Attached Carport Detached - 1 Car Detached - 2 Car Detached - 3 Car Detached Carport No Garage Other
Square Footage of Location Optional
Security System Optional	select None Monitored Unmonitored Unsure
Fire Alarm Optional	select None Monitored Unmonitored Unsure
Any special considerations
Do you have any of the following breeds of dogs: Chow, Doberman, German Shepherd, Pit Bull, Rottweiler, Wolf Hybrid or a mix of these? Optional	Yes No
Is your home located in a flood plain? Optional	Yes No
Select any additional property features that apply (optional): Optional	DeadBolts Fire Extinguisher Trampoline Covered Deck/Patio Swimming Pool

What type of coverage do you need?
Replacement cost of dwelling (not including land) Required Replacement cost of dwelling (not including land) is required.
Liability Limit Optional	select $100,000 $250,000 $500,000
Deductible Amount Optional	select 250 500 1000
Have you reported any claims or losses to your insurance company within the past 5 years? Optional	Yes No
Will this insurance replace an existing policy? Required Will this insurance replace an existing policy? is required.	Yes No
Current Insurance Provider Optional
Current Policy End Date Optional	Open the calendar popup. << < February 2012 > >>   S M T W T F S 5 29 30 31 1 2 3 4 6 5 6 7 8 9 10 11 7 12 13 14 15 16 17 18 8 19 20 21 22 23 24 25 9 26 27 28 29 1 2 3 10 4 5 6 7 8 9 10

Personal Information
First Name Required Input Required
Last Name Required Input Required
Gender Required Input Required	select Male Female
E-Mail Address Required You must provide an e-mail address. A valid e-mail address is required.
Primary Phone Number Required Input Required Please enter a valid phone number
Alternate Phone Number Optional Please enter a valid phone number
Additional Information Optional
Check here to receive the AJM Newsletter. Optional
Enter Validation Code Required

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