Buying a home is an exciting accomplishment, one with many new responsibilities. Not only will you want to protect your home and its valuable contents, you will also want to shield yourself and your assets from exposure to liability arising from personal injury or property damage claims. Fill out the form below to receive a quote. Let us help you find the very best coverage for your most valuable possession. Home Insurance Quote Request Form Please fill out the preliminary form below and an agent will contact you. If you would prefer to speak directly to an agent, simply fill out the fields highlighted in blue. Basic Information First Name Last Name Address Address City State (**) Zip (*****) Phone Number (***-***-****) Email What Type of Dwelling Coverage Do You Need? Home Rental Condo Fire What is the Estimated Replacement Cost of the Dwelling? What Amount of Insurance Is Required by Mortgagee? What is the Name of the Mortgage Company? Dwelling Description How Many Families Live in the Dwelling? (1-10) How Many Stories Are On the Dwelling? (1-10) What Year Was the Dwelling Built? (****) What Type of Construction is the Dwelling? Frame Brick Log Other How Many Square Feet Are On the Main Floor? Sq Ft. What Type of Roof is on the Dwelling(shingle,shake, etc.)? Does the Dwelling Have a Basement? Yes No How Many Square Feet Are in the Basement? Sq Ft. Finished Unfinished Does the Dwelling Have a Garage? Yes No What Type of Garage(choose all that apply)? Structure Type... Frame Brick Metal Proximity... Attached Detached Built-In Basement Capacity... 1-car 2-car 3-car Other Please Identify Other Structures on the Property and Their Replacement Cost: How Many Bathrooms Are in the Dwelling? Full 3/4 1/2 How Many Fireplaces/Woodstoves Are in the Dwelling? (1-10) Please Identify Any Other Dwelling Add-Ons and Their Size: Sq Ft. Sq Ft. Sq Ft. Special/Additional Coverages Would You Like to Request Increased Limits on Valuables? Yes No Please Identify Additional Categories and their Value? Jewelry Silverware Furs Guns Fine Arts Cameras Computers Other Jewelry Silverware Furs Guns Fine Arts Cameras Computers Other Jewelry Silverware Furs Guns Fine Arts Cameras Computers Other Jewelry Silverware Furs Guns Fine Arts Cameras Computers Other Please Identify Any Other Special Coverages You Would Like: Earthquake Flood Sewer Please Identify Any Other Protective Device in the Dwelling: Smoke Detectors Dead Bolt Locks Fire Extinguishers Alarms Smoke Detectors Dead Bolt Locks Fire Extinguishers Alarms Prior Insurance Information Who Is Your Current Insurance Carrier? How Much is Your Coverage? What Is the Expiration Date? January February March April May June July August September October November December , 2000 2001 2002 2003 2004 2005 Have You Had an Insurance Claim Within the Last 36 Months? Yes No   Pacific Insurance Agency 8306 N. Wall St. Suite A Spokane, WA 99208 Phone: (509) 465-1133 (800) 600-4303 FAX: (509) 465-1134 info@pacific-insurance.com The Agency | Employee Benefits | Resources Home | Commercial | Life | Auto ©2000 Pacific Insurance Agency, Inc. All Rights Reserved.