Dave McChesney
Agency

1798 East Route 66
Flagstaff, AZ 86004
520-774-3553 Fax: 520-774-9020
1-800-734-7940


HOMEOWNERS / RENTERS QUOTE FORM

Please Note: If you prefer not to complete this form, you may obtain a quote by faxing your current homeowners declaration page to 520-774-9020

PERSONAL INFORMATION

Name:
Address:
City:
State: Arizona
Zip Code:
E-Mail Address:
Phone Number
Fax Number (Optional)
Current Insurance Company:
Expiration Date:
Policy #

Home Location

Physical Address of Home:
City:
County:
State: ARIZONA
Zip Code:
Inside City Limits or Outside:

Rating Data

Total Square Footage of Home:
Year Home was Built:
Construction of Home:
Roof Construction:
Number of Levels:
Number of Bedrooms:
Number of Bathrooms:

Value

Estimated Value to TOTALLY Replace Home
ie: the amount of Insurance Needed on Home
Estimated value to TOTALLY replace personal effects

Claims

Any claims on Home in past 3 years:
If Yes, Please enter Date of Loss, Amount
of Loss and Cause of Loss

Deductible

Please Choose a Deductible:
Any Comments you feel may be
necessary in providing you with this quote: ie: antiques, collectibles, guns, jewelry, etc.

Thank you for completing our online quote form. We will send you a quote within two business days. Please let us know how you would like us to send you the quote:

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