GHM Insurance Agency

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Homeowner's Quote Form

Note: Offer only pertains to residents of Maine or anyone relocating to Maine

Please fill out the following form, and then click on the "Submit Quote" button. Your request will be processed and you will receive a quote soon.

Applicant Info

Name:

Your email address:

Mailing Address:

City:

State:

Zip Code:

Phone #:

Social Security #:

Additional Info
Please fill in as much information as possible.

Location of House (if different from mailing address):

Year house was built:

Style of house:

Structure: Frame Brick

Number of families:

Do you have a garage? Yes No

If so, is it: Attached Detached

Type of Heating System: Age:

Age of plumbing:

Age of roof:

Age of wiring:

Do you have a wood or coal stove?	yes no

Do you have smoke detectors?	yes no

Do you have fire extinguishers?	yes no

Do you have dead bolts?	yes no

How many feet to the nearest fire hydrant?

How many miles to the nearest fire station?

Have you had any homeowner claims within the last 5 years?	yes no
If so, please explain:

Are there any other structures on the premises? yes no If so, please describe:

Do you have any pets? yes no If so, please list what types and how many. If you have any dogs, please describe any history of biting or aggressive behavior, if any:

Does any member of the house smoke? yes no Who's name is on the deed?

Insurance Info Please fill in information about current coverages, and your desired coverages.

How much is your house insured for now? Is it adequate? yes no


How much liability do you have?

How much is the deductible?

Does your policy replace contents?	yes no

Does it replace the dwelling?	yes no

Do you have any items scheduled currently
(ex: jewelry, furs, guns, antiques)? yes no
Please describe the items and value them here:

I would like to receive my quote by:

What is the best time to contact you by phone?

Anything else we may need to know?

© GHM Agency 2004

Disclaimer: Please be advised that no insurance can be purchased, bound, or put into effect over the GHM Agency website. To start a policy or make changes to an existing policy, you must first speak with a GHM agent who will assist you accordingly. Thank You.