SIEGEL INSURANCE, INC.
Homeowners Insurance Quote

Georgia Residents Only 

Your Name:       

Address:          

City:                  State:   Zip Code: 

County:           

Home Phone:   Work:  Fax: 

E-Mail Address: 

Date of Birth:    

---

The some of the following questions may require information contained on your current homeowners policy. If you do not have your current policy available for review leave the "answer" provided. You may leave comments or questions at the end of the questionnaire.

Residence Information

HO Form Select Home Owner Tenant/Renter Condominium Owner

Inside City Limits? Yes No

Is This a Primary or Secondary Residence? Select Primary Secondary Year Built

Construction Type Select Frame Stucco Brick

Deductible Amount Select 100 250 500 1000 2500

Replacement Value of Residence:

Coverage Information

Personal Liability Select 100,000 200,000 300,000 400,000 500,000 1,000,000

Medical Payments Select 1000 2000 3000 4000 5000 10000

Replacement Cost Options

Replacement Cost on Dwelling
Replacement Cost on Contents

Protective Devices

Smoke Detectors
Dead Bolt Locks
Fire Extinguisher
Non Smoker
Central Station Burglar Alarm (rings at a monitoring center)
Central Station Fire Alarm (rings at a monitoring station)
Police Station Direct Alarm (rings at police station)
Fire Station Direct Alarm (rings at fire station)
Local Burlar Alarm (rings on the premises only)
Local Fire Alarm (rings on the premises only)
Automatic Sprinkler - All Areas
Automatic Sprinkler - Excluding Attic, Bath, Closet

Additional Coverages

Scheduled Property - Enter Total Dollar Amount of Itemized Coverage for each Category

Silverware:       
Camera:           
Musical Instr.:   
Personal Furs:    
Personal Jewelry: 
Jewelry in Vaults:
Guns:             
Golf Equipment:   

Earthquake Coverage? (Not Covered unless you select coverage) Select No Yes

Flood Coverage? (Not Covered unless you select coverage) Select No Yes


Please list all claims and amounts paid for the last 3 years:

Use this area for any special comments or coverages which need special attention.




Do you currently have homeowners insurance? Yes No
Who is you current homeowners insurance company?
When does your current policy expire?