A.H. Meyers Online HomeOwners Quote Form
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Please provide the following contact information:
Day Phone
Eve. Phone
Date of Birth
Send Quotes via
Choose The Reason You Require Homeowners Insurance:
New Purchase
Policy Canceled
Policy Lapsed
Paying Too  Much
How many claims have you made in the last 5 years?(give claim details and dates in section)
Current Insurance Company (if none, please type none)
Policy Expiration Date
Type of Home
  One Family
Two Family
Three Family
Four or More
Occupancy:(check all that apply)
Owner Occupied
Rented to Others
Second Home
Owner & Tenant

Specific Information on the Home

Construction of Home
Wood Frame/Vinyl or Aluminum siding
Style of Home
Number of Stories
(excluding basement)
Approximate living area in square feet
(excluding basement)
What year was the home built?   Approximate if unsure.
What type of Foundation supports the home
Concrete Slab
Crawl Space
Basement (unfinished)
Roofing Material
Asphalt or Architectural Shingles
Clay or Spanish Tile
Wood Shake (very old homes)
 Roofing shingles last replaced
(enter year, original, or unsure)
Type of Heating
 Oil or Gas Burner replaced or updated
(enter year, original, or unsure)
If oil heat, where is the tank?
Buried in ground
Above ground
In crawl space or basement
Electrical System
 How many amps in electrical service
 Does your electrical system have circuit breakers?
Yes  No
 Electrical System Upgraded
(enter year, original, or unsure)
Garage Type
# of cars garage holds
Security Features (check all that apply)
Smoke Detectors
Fire Extinguishers
Dead Bolts
Local Burglar Alarm(rings outside home)
Local Fire Alarm (rings outside home)
Central Station Burglar Alarm
Central Station Fire Alarm (Central station means connected directly to a monitoring facility that contacts police or fire dept on your behalf)
Home Features
  Central Air
Number of Bathrooms
# Fireplaces
  Wood Stove Yes No  
  Swimming Pool  
  If yes, Diving Bd. Yes No  
If yes, fenced in Yes No

Insurance Coverages

Insurance Coverages
 What is the purchase price of the dwelling?
Mortgage Amount
Dwelling Amount 
Personal Property Cov.
Personal Liability Cov
Building Deductible 
Is Flood Coverage Required? Yes No
If  Flood is requested, how much coverage is needed?
Flood deductible
Do you need coverage for scheduled personal property (jewels, furs, silver) beyond what the standard policy offers? Usually big ticket items.  Yes  No
If yes, give amt in $'s for each
example $12,000
Jewelry $
Furs     $
Silver    $
Underwriting Questions
Underwriting questions (as you may know, credit has become a major factor in obtaining insurance in a number of states, so please be aware that where applicable, rates will be quoted based on your responses below)
Filed For Bankruptcy in last 5 years? Yes No
Do you have a dog?
If so, what breed(s)
Yes No
Other types of insurance we have: Auto  
Business Auto