Home Quote Hello, please fill this in… Thank You! Erik Obrycki – Ackerly Agency Inc. Your Email (required) Full Name (required) DOB(required) 2nd Name Insured 2nd Name DOB Married? Req. —Please choose an option—YesNo Credit Score Req. —Please choose an option—ExcellentAbove AverageAverageBelow Average Effective Date(required) Current Carrier (required) Phone Number (required) Location Address (required) City Req. Zip Code Req. House Construction Type (wood / mas.)(required) Wood FrameConcreteMetal Owner or Tenant Occupied? (required) OwnerTenantVacant How Many Family?(required) 1234 Year the home was built? required) Number of Stories (required) Gas or Oil Heat? GasOil w/above Ground TankOil w/ Under Ground TankPropane Single Family or Townhouse? (required) SingleTownhouse Years at current residence?required) Miles to Fire Dept? (required) Feet to Fire Hydrant? (required) Year of updates, if home over 30 years old Wiring yr upgrade? Heating System yr upgrade? Plumbing yr upgrade Roof year replaced? Req. Roof Type Req. —Please choose an option—GableHipPartial Hip (75%-89% Hip)FlatGambrelMansardComplex/CustomReinforced Concrete Shingle Type Req. —Please choose an option—3 Tab AsphaltArchitectural AsphaltCopperMetalSlateTile Dwelling Square Feet Req. Swimming Pool? Req. YesNo Trampoline? req. YesNo Pets? req. NoneDogsCats Wood burning Stove, Fireplace, Pellet Stove? Req. NoneWood StovePelletFireplace Smoke Detectors on all levels? Req. —Please choose an option—YesNo Fire Extinguisher? Req. —Please choose an option—NoYes Fire Sprinkler System? Req. —Please choose an option—NoYes Central Alarm? Req. NoneFireBurglarBoth Dead Bolt Locks on all Exterior doors? Req. —Please choose an option—YesNo Home Owner Association? Req. NoYes Have been cancelled in the last 3 years? Req. —Please choose an option—NoYes If yes Why? Have you had and lose reported to the company in the past 3 years even if no payout? —Please choose an option—NoYes If yes why?
