Homeowner Quote
Combined Shape
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Please Complete the Form Below
If you have any questions, please reach out to Tim Miles or Mike Dale at 480-985-7745 or email us at
tim@valleyig.com
or
mike@valleyig.com
Applicant Information:
Applicant Full Name
Applicant Date of Birth
Applicant Occupation
Co Applicant Information:
Co Applicant Full Name
Co Applicant Date of Birth
Co Applicant Occupation
Co Applicant Phone
Co Applicant Email
Trust or LLC
Primary Home Address:
Primary Address:
Address of Premises if Different
Current Insurance Carrier:
Current Insurance Carrier
Policy End Date
Any Home Claims in the past 5 years
Claim Amount
If Yes, Please Explain
Home Details:
Home Use
Primary
Secondary
Seasonal
Short Term Rental
Purchase Price
Purchase Date
Square footage
Separate Structure Square Footage
Separate Structure Use
Rental Usage
Construction Type
Frame
Log
Log Veneer
Siding
Other
Interior Design
Standard
Semi Custom
Custom
Heat/AC Type
Fireplace/Stove
Fireplace
Gas Fireplace
Wood Stove
Pellet Stove
Roof Type
# of Bedrooms
# of Bathrooms
# of Stories
Distance to closest Fire Hydrant
1000 feet
1000 feet or more
Distance to Nearest Fire Department
Monitored Alarm System & Provider
Home Updates/Renovations Year
Other Updates
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