Commerce Group, Inc.
Home Quote
Page 1
page 1 of 3
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
---------
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
American Samoa
Guam
Marshall Islands
Micronesia
Northern Marianas
Palau
Puerto Rico
Trust Territories
Virgin Islands
Armed Forces(AA)
Armed Forces(AE)
Armed Forces(AP)
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Northwest Territory
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon Territory
City
State
Zip Code
Location address if different from mailing
Address
Address Line 2
---------
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
American Samoa
Guam
Marshall Islands
Micronesia
Northern Marianas
Palau
Puerto Rico
Trust Territories
Virgin Islands
Armed Forces(AA)
Armed Forces(AE)
Armed Forces(AP)
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Northwest Territory
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon Territory
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
Page 2
page 2 of 3
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
Page 3
page 3 of 3
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
* required