Homeowners or Renters Quote Request

How did you hear about SSM:
Effective Date:
Your Name:
Your Mailing Address: Street
City                                 State                                 Zip
     
Date of Birth   Spouse's Date of Birth:
Your Preference: Please call me with quote
Please send quote via e-mail
E-mail Address:
Daytime Phone #:
Cell Phone:
Evening Phone #:
Best Time to Call:
Current coverage: Company:                         Expiration Date:
  
Type of policy desired:
Property Information:
What is the construction type of your home?
 		In what year was your home built?
In what County are you located?
 		Distance to the nearest fire hydrant?
What kind of pets do you have?
 		Do you have a swimming pool?
 Yes No
Do you have a trampoline?
 Yes No 		Do you have a wood or solid fuel burner?
 Yes No
Smoke Detectors Installed
 Home Security System Installed
 		 Do you own farm ground/other real estate? 
Yes   No
Do you own a business?
 Yes No
 		 Have you filed bankruptcy in the past 5 years? 
Yes   No
Home Updates:  Enter year updates were made. If year not known, enter "unknown":
Roof:

Wiring:
 		Plumbing:

Heating:
Amount of insurance requested:
Homeowners only:
What is the limit of insurance on your home?

Condo/Renters only:
What is the value of your personal contents?
Liability Limit:


Medical Payments:
Valuation of Home:

Personal Property Valuation:
 		Deductible:

 
Optional Property Coverage:
 
Earthquake Coverage Requested
 Flood Coverage Requested
 Sewer/Water Backup Coverage Requested
Identity Theft
Replacement Cost on Contents
 
Property Floaters - Indicate limits below:
 
Antiques:

Coins:

Computers:

Fine Arts:

Furs:

Guns:

Jewelry:

Stamps:

Tools:

Boat/Recreational Vehicles:
Other Floater Coverage:     Limit of Insurance:
             
Previous Loss Information
Please describe any losses or claims filed on your Homeowners Insurance in the last 3 years including date, type and amount of claim:
 

Is it okay if we run your insurance score?  Yes    No

 
Are there coverages missing on your current policy:

What are you unhappy with on your current policy:

What other policies do you have and when do you review them?

 Please use the box below to enter any additional information:

Do you make your insurance decisions alone or with another person?  Alone    With Another Person

When is the best time for you to come to our office and discuss your coverage with one of our agents?
 
We cannot bind coverage from an email or voicemail request.  Coverage is bound after you receive a written email or telephone call from our agency staff confirming coverage is in force.

Thank you for allowing us to review your coverage!  If you have not heard from us within one business day please contact us again.

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  Stahl Stoller Meyer Insurance Center: Paulding Location: 419-399-3777 • Van Wert Location: 419-232-4776

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