LaVan Insurance Agency

Home Insurance Quote
Please fill out the form below and we will in contact with you within the next business day.

Applicant / Titleholder

Last Name:		Pref Language:
First Name:
Address:		Phone:
City:		Email:
State:		How would you like us to contact you?
Zip:		How did you hear about us?

Current Insurance

Do you currently have insurance? How long without a lapse in coverage?
If YES, please complete the following:
	Company Name:
	Number of years claim free:
	Number of years with them:
	When does the policy expire:
Is the policy being cancelled or non-renewed?

Property Information

Property Address (if different)
Property City, State, Zip
What year was building built?
What condition is building in?
What type of construction?	(majority of building)
Who lives in the building?
How many families live in building?
How many stories is the building?
What ELECTRICAL systems does it have?
When was it last updated?
What HEATING system does it have?
When was it last updated?
When was the PLUMBING last updated?
When was the ROOF last updated?
Is the following present on building?
Dead Bolt Locks	Smoke Detectors: Fire Extinguishers:
Does building have any dogs?
If yes, how many and what kind?

Coverages

Limits of Liability (BI & PD)
Medical Payments
Building Coverage
Building Coverage Deductible

Other Info

Some insurance companies use credit scoring to determine their rate. This will not affect your credit and will not be shown as an "inquiry" to your credit report.
Do you want to be considered for these quotes?
If yes, what is the primary's date of birth?
Comments:

Thank you for taking the time to complete this form. We will be in contact with you as soon as we have your quote ready.