Collins Insurance, Inc. -- Free, homeowners insurance quote, request form.
Fill out this form with your information and then click the " Submit form " button.
Please do not click the " Submit form " button more than once.
A red * = a required field.
 


* First name:  
Initial:
* Last name:  
* Address line 1:  
Address line 2:
* City:  
* State:
* Zip:  
* Birthdate:  
* Soc. Sec. #:   Example: 123456789 (No dashes)
* Home phone #:   Example: 1234567890 Area code + Phone number (No dashes)
* Work phone #:   Example: 1234567890 Area code + Phone number (No dashes)
* Email address:   Example: you@xyz.com
* Verify email address:  
   
Current Homeowners Insurance Information (If applicable)
 
Company name (not agency):
Policy expiration date:
Premium amount $:
Amount insured for $:
   
Home Information
 
* Year home was built:
* Square footage ground floor including garage: sq. ft.
* Number of stories:
* Number of claims in the last 5 years:
Construction:
Roof:
* Age of roof: years.
Foundation:
If your home has a basement, what percentage is finished: %
Circuit breakers or fuses:
Do you have a trampoline:
Do you have any pets: If yes, explain
Do you have a swimming pool:
If you have a swimming pool is it fenced in:
If you have a swimming pool do you have a diving board:
If you have a swimming pool do you have a sliding board:
   
Features
 
Bathrooms: Number of full Number of half
Deck: sq. ft.
Porch: sq. ft.
Screened patio: sq. ft.
Number of fireplaces: Please explain ex. wood, gas insert, etc...
Heating system:
Supplemental heating:
Security alarm:
Fire alarm:
Smoke detector:
   
Desired Coverages
 
Liability limit:





   
Deductible:




   
Additional Comments
  Please give any additional comments you feel appropriate for this quotation. If you have additional information where enough space was not given, please enter the additional info here.