Pennsylvania insurance
Pennsylvania insurance
Insurance Resources for Pennsylvania Business Owners & Residents
Pennsylvania's Online Insurance Sales & Service Leader!
Pennsylvania insurance

Pennsylvania insurance
Pennsylvania insurance
Click Below to
Receive Your Free
Insurance Quote:

  Auto Insurance Quotes
  Home Insurance Quotes
  Mobilehome Quotes
  Renters Insurance Quotes
  Motorcycle Insurance Quotes
  Boat Insurance Quotes
  Snowmobile Quotes
  Personal Umbrella Quotes

  Business Owners Quotes
  Business Auto Quotes
  Workers' Compensation
  Contractor Program Quotes
  Directors & Officers Liability
  Professional Liability Quotes
  Liquor Liability Quotes
  Business Umbrella Quotes

  Group Health Quotes
  Group Dental & Vision
  Group Disability Quotes
  Group Life Quotes
  Individual Health Quotes
  Individual Disability
  Individual Life Insurance
  Long Term Care Quotes
  Dental Insurance Quotes
  Vision Insurance Quotes

  Farm Insurance Quotes
  Rental Property Quotes
  Flood Insurance Quotes
  Equine Mortality & Liability
  Special Event Quotes
  Special Financial Planning
     & Products for your Future

  Service My Account
  Claims
  Companies We Represent
  Research & Links
  About Our Agency
  Return to Home Page

Questions?
We'd Love to
Hear From You.

 
E-mail us any questions you may have:

 
insurance@valley-agency.com



Homeowners Insurance
Quotation Form
One Simple Form - takes only 2-3 Minutes!


Your Personal Data:
 
Your Name:
Property Address:
City:
Your "County" is?
Click State:
(* We are only licensed
in Pennsylvania and Maryland.)
Zip/Postal:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
 
 
Dwelling Information
 
Year Home Built:
Home Square footage:
 
Is this Builder's Risk?
(new home constr.)
NO YES
 
Month/Year home
to be complete:
 
Number of units: 1 family Duplex
 
Type foundation: Slab
Crawlspace over slab
Pier & Post
Other (list in remarks)
 
Type Construction: Frame
Brick/Veneer
Stone
Other (list in remarks)
 
Type Roof: Shingle
Wood Shake
Tar/Gravel
Spanish Tile
Metal Other
 
Number of stories: One 1.5
Two Three
 
Do you own animals or pets? Yes No
If yes, list type/for dogs, list breed:
 
Are You Near Brush Area? Yes No
 
# of feet to nearest
fire hydrant:
# of miles to nearest
fire station:
 
Currently Insured? Yes No
Name of Carrier & how long insured?
 
Prior Claims? Yes No
Describe claims in detail:
 
Rate Your Credit History and Past Insurance Payment History:
(Some companies products are
based on your credit and payment history.)
Excellent Fair
Poor Horrible
 
Plumbing type: Copper Galvanized
Mixed (Copper/Galvanized)
 
Circuit Breakers or fuses? Breakers Fuses

# Bedrooms: # Bathrooms:
 
# Fireplaces: # Chimneys:
 
Special features
(i.e., deck, air conditioning, alarm systems, pool, etc.)
 
Coverages:
 
Dwelling Cov. $ Contents $
Liability Cov. $ Deductible $
($250, $500, $1,000, etc.)
 
Comments/Remarks
(describe any scheduled jewelry, in-home business, or other special coverages needed here):
 
Send my quotation via: E-Mail Fax
Regular Mail
Call Me By Phone

Thank you for filling out this form COMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

Yes, I Agree. Please Send Me a Quote NOW!


Click Button Below When Done

Please Click Only Once . . . May take up to 30 seconds!


Terms of Use/Privacy Notice/Copyright Info. Valley Agency.    Design © 2005 Insurance-Web-Sales
Please report site-related technical problems to: insurance@valley-agency.com (This page last updated 02-05-05)