J and L Insurance | Homeowner's Insurance Quote Page

Single Family Home Information Form

Please fill out this form to give us the opportunity to give you the best quote for your home.

Contact Information First Name:
Last Name:
Home Telephone:
Mobile/Business Telephone:
Email:

General Property Information Street Address:
City::
State:
Zip Code:

New Home Re-Finance

Current Insurance Company:

Type of Residence: Primary Secondary Rental

Homestead Property? Yes No

Number of Bedrooms:
Number of Bathrooms:
Square Footage:
How Many Floors?
Year Built:

Construction Type: Wood Frame Masonry/Concrete

Roof Covering:

Is there a Pool?

No Pool
Yes, in a Fenced Yard
Yes, in a Fenced Yard w/ Screen Enclosure
Yes, Screen Enclosure Only

Do You have Dogs? Yes No

Security & Protection Central Station Alarm System? Yes No

Deadbolts? Yes No

Smoke Detectors? Yes No

Hurricane Shutters? Yes No

Coverage Amount

Select the replacement value of your home.
Note: Coverage is for Dwelling only, and doesn't include land value.

Coverage Amount for Renter's Insurance

Personal Property Value $