Homeowners

Thank you for the opportunity to quote your business. Please completely fill out the form and email it to us to receive a no-obligation quote. Three Rivers Agency, Inc values your privacy and will not sell, disclose or share your information with other parties without your consent.

Please give us a call at (208) 642-9311 if you have any questions about the questionnaire.
Demarius Maiello
Personal Lines CSR • Caldwell Branch
Download the Homeowners Quote Form by clicking here.
HOMEOWNERS QUOTE FORM
Address:
City:
State:
Zip/Postal Code:
Stated (market) value of home:
Replacement value of home:
Liability limits desired:
(i.e. $100,000 - $300,000 - $500,000 - $1 Million)
Medical Payments:
(i.e. $1,000 - $5,000)
Deductible Requested:
(i.e. $250 - $500 - $1,000)
Mortgagee:
Mortgagee Address:
Do you have a escrow account that pays your annual premium?
If Manufactured Home: Make
Model
Year
Serial Number:
Type of foundation:
(i.e. concrete, block,
tye-downs)
Any porches, decks or patios?
  If Yes, give dimensions & description:
Attached Garage? Number of Cars:
Number of FULL bathrooms: Total number
of bathrooms:
Number of stories above ground:
Basement? Is it finished?
Exterior siding:
(wood, vinyl, etc)
Physical measurements:
(i.e. square footage or length & width)
Age of dwelling:
(in years)		 Type of dwelling:
(frame, masonry, etc.)
Type of roof:
(tile, asphalt shingle, wood shake, etc.) 		Age of roof:
(in years)
Type of heat:
(gas, electric)		 Do you have
supplemental heat?
(woodstove,fireplace)
Type of Air Condintioner:
(wall unit, heat ducts)
Do you have fuses / knob & tube? Does the home use
only circuit breakers?
Responding fire department: Miles to fire
deptartment:
Any pets?
  Describe:
Swimming Pool? Trampoline?
Do you own have an in-home business? Do you own a
cabin/condo?
Is the location farm, residential, or mixed commercial?
Any tractors? Any farm animals?
Any Acerage?
If Yes to any of the three above, please describe below:
Any recreational vehicles? (i.e. jetskis, boats, four-wheelers):
If liability or physical damage coverage is requested, please indicate:
Year: Make
Model: # of CC's:
Value:
Year: Make
Model: # of CC's:
Value:
Year: Make
Model: # of CC's:
Value:
Year: Make
Model: # of CC's:
Value:
YOUR (INSURED) INFORMATION
Name:
Date of Birth:
(00/00/00)
Social Security Number:
Address:
City:
State:
Zip:
Phone:
Email Address:
Other members of the household:
Name: Date of Birth:
(00/00/00)
Relationship:
Name: Date of Birth:
(00/00/00)
Relationship:
Name: Date of Birth:
(00/00/00)
Relationship:
Name: Date of Birth:
(00/00/00)
Relationship:
Present Occupation:
Employer:
Spouse Occupation:
Employer:
Years at present occupation: (you)    (spouse)
Years in current home:
Current Insurance Carrier:
How long with current carrier?
Prior Insurance Claims?
  If yes, provide details, dates, loss amounts:
INSURED'S STATEMENT:
By completing this form the applicant hereby authorizes and grants permission to Three Rivers Agency, Inc, it’s agents or affiliates to make inquiry of the applicant’s previous insurance carriers and to obtain a credit report. Applicant understands and agrees that information obtained from these sources may be utilized in determination of applicant’s eligibility for acceptance. Applicant declares all statements herein are truce and correct to the best of his/her knowledge.
Fill in full, legal name:
Date:
Comments:
Three Rivers Insurance Address