IMPORTANT NOTICE
1. This homeowner's insurance quote request applies only to the states of Oregon and Washington. Do not fill out this form if you do not live and own a home in Oregon or Washington.

2. No insurance will be started by submitting this form. Coverage may be placed in force only after you decide to purchase it from us, and then after you complete and sign the insurance application and pay the initial premium.

3. Submitting the following quote request constitutes your agreement with the above statements. We will contact you within two business days after we receive your request. If you have questions concerning this notice or about the following form, please call us at 503-620-0230 or 1-888-620-0230.

 
Homeowner Insurance Quote Request
  1. Your first name
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  2. Middle name
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  3. Last name
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  4. Phone number
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  5. Email address
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  6. Fax number
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  7. Your date of birth
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  8. Your social security number
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  9. Marital Status
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  10. Describe your occupation
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  11. Name of additional person to be insured
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  12. Relation to applicant
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  13. Date of birth of added person
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  14. Social security number of added person
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  15. Occupation of additional person
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  16. Marital Status
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  17. Street address
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  18. City
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  19. State
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  20. Zip code
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  21. County
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  22. Is the mailing address the same as the property address?
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  23. Effective date of coverage
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  24. Amount of dwelling coverage
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  25. Amount of contents coverage
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  26. What deductible would you like
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  27. What limit for personal liability would you like
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  28. What limit would you like for medical payments
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  29. Names of All Mortgagees
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  30. How many people live in your household?
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  31. Is your home under construction?
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  32. Do you operate a business in your home?
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  33. If "yes", describe the business and its size
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  34. Describe breed of dogs in household
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  35. Has a dog of yours ever attacked or bitten anyone?
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  36. Describe horses, livestock or exotic animals
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  37. Current Insurance Company
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  38. Has coverage been cancelled, declined or non-renewed in last 5 years?
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  39. Month and year you became homeowner
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  40. Do you now have other coverages with us?
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  41. Year Originally Built
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  42. Construction Style
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  43. Dwelling Type
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  44. Current dwelling condition
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  45. Roof material
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  46. Year Updated Roof
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  47. Main Heat Source
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  48. Year Updated Heating
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  49. Year Updated Plumbing
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  50. Year Updated Electrical
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  51. Exterior Walls
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  52. Foundation
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  53. Number of 3/4 bathrooms
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  54. Number of full bathrooms
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  55. Number of half bathrooms
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  56. Number of stories, not including attic or basement
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  57. Describe All Security Devices
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  58. Total square feet of living area
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  59. Additional Information or Comments
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  60. Re-type the Security Field numbers in the box
  61. Security Field
    Security Field
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  62. To keep a copy of this form, please Print before Submitting
  63.   

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Questions?

If you have questions concerning this information, please call us at 503-620-0230, or come in.

Llámenos ya al 503-620-0230.