Commerce Group, Inc.

Home Quote

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If you wish to receive an accurate quote, please fill out the form completely. If you prefer you can give us your contact information only, and we will contact you by the next business day.

First Name required

Middle Initial required

Last Name required

Current Occupation required

Highest Level of Education Completed required

Date of Birth required

Click in box to select date

Gender select one

Select one

male
female

Marital Status select one

Select one

single
married

Spouse's Name required


First Name	Last Name

Current Occupation required

Highest Level of Education Completed required

Spouse's Date of Birth required

Click in box to select date

Gender select one

Select one

male
female

Marital Status select one

Select one

single
married

Mailing Address


Address

Address Line 2

City	State	Zip Code

Location address if different from mailing


Address

Address Line 2

City	State	Zip Code

Home Phone required

Phone Number

Work Phone required

Phone Number

Email required

Email Address

Do you have any pets? select one

Select one

yes
no

If so, what type of pet and what breed? (If farm animal, what kind and how many?) required

Have you had continuous coverage for at least 12 months? select one

Select one

yes
no

If not, why? required

Current Insurance Company required

Current Insurance dwelling coverage amount required

Renewal Date required

Click in box to select date

Claims in the last 5 years select one

Select one

None
1
2
3
4 or more

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Square footage of living space (not including basement or attic even if finished) required

Year home was built required

Click in box to select date

Electrical Updated? select one

Select one

Yes
No

If yes, Please provide date required

Click in box to select date

Plumbing Updated? select one

Select one

Yes
No

If yes, Please provide date required

Click in box to select date

Furnace Updated? select one

Select one

Yes
No

If yes, Please provide date required

Click in box to select date

How many stories select one

Select one

1 Story
1.5 Story
2 Story
Split Level

Style of home select one

Select one

Ranch
Bungalow
Rambler
Queen Ann
Cape Code
Colonial
Mediterranean
Southwest Adobe
Victorian
Row house/town house end
Row House/town house middle
split level
Tri-level

Construction select one

Select one

Frame
Stucco
Masonry
Masonry Veneer

Foundation select one

Select one

Basement
Crawl Space
Slab

If Basement, % that is finished required

Roof select one

Select one

Asphalt
Wood Shingle
Tile or Slate
Other

Age of Roof required

Garage Size select one

Select one

1 Car
2 Car
3 Car
4 Car

Garage attached or detached select one

Select one

attached
detached

Any other structures on the premise besides the home? (i.e, fences, sheds, gazebos, barns) required

Full Bathrooms select one

Select one

1
2
3
4
5

Half Bathrooms select one

Select one

1
2
3
4
5

Air conditioning select one

Select one

yes
no

Fireplace select one

Select one

yes
no

If yes, what kind and how many required

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Deck? select one

Select one

Yes
No

If yes, Sq. Ft? required

Porch? select one

Select one

Yes
No

If yes, Sq. Ft? required

Screened Patio? select one

Select one

Yes
No

If yes, Sq. Ft? required

Enclosed Porch select one

Select one

Yes
No

If yes, Sq. Ft? required

Is there a burglar alarm select one

Select one

yes
no

Is there any business being conducted on the premise select one

Select one

yes
no

If yes, what kind of business required

Pool, hot tub or trampoline select one

Select one

yes
no

If yes, what kind required

Please call our office during business hours to provide your Social Security number.

Other Comments required

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This form is generated and maintained by Commerce Group, Inc..
For refund (if applicable) and privacy policies please contact Commerce Group, Inc. at www.commercegroup.net.