Hollingsworth Insurance Services

Homeowners Insurance Quote
We would like to provide you with a free, no-obligation homeowners insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

Agent Information
           Agent Name:
Phone: Fax:
Email Address:

Required*   Applicant acknowledges that a CLUE Report
CLUE Report

Comprehensive Loss Underwriting Exchange: Underwriters use the information in a CLUE report to rate insurance policies. A home's CLUE loss history report provides insurance company names and policy numbers and any claim numbers. The report lists the dates of any claims, the loss types and amounts paid for losses, and it will tell if a claim was denied.
may be obtained during the quoting process

Applicant's Personal Information
Applicant Name:   DOB:   Gender:
Marital Status:   Occupation:
Co-Applicant Name:   DOB:   Gender:
Marital Status:   Occupation:
Property Address:
City:   State:   Zip:
In City Limits?: Yes   No
Prior Address:
(If at Property Address less than 2 years)
City:   State:   Zip:
Mailing Address:
(If different from Property Address)
City:   State:   Zip:
Email Address:

Current Homeowners Insurance Information
Company Name (not agency):
Policy Information: Expiration Date Premium Amount Amount Insured For
$ $
     If rental, how many units owned by the applicant:  
Current Deductible: $     # of Mortgages:
# of Claims In Last 3 Years: Date: Amount: Details:

Please list losses here

New Coverage Information
Amount of Coverage Desired: $
Desired Deductible: $
Personal Liability: $
Earthquake Coverage: Yes   No
Extended Coverage: $

Home Information
How Long At Present Address:     Year Home Was Built:
Swimming Pool?: Yes No         If Yes, Diving Board: Yes No
Any Pets?: Yes No
If Yes, what kind / how many:
Sq. Footage:
(excl. garage/basement)
sq. ft.       # of Units:
Miles to Responding Fire Dept.:     Feet to Fire Hydrant:
If home is more than 20 years old, please provide updated information for the following:
Roof: Year Updated:   Complete Partial None
Electrical: Year Updated:   Complete Partial None
Heating: Year Updated:   Complete Partial None
Plumbing: Year Updated:   Complete Partial None

Structure Information
Exterior Walls
Age of roof: yrs.

Deck/Porch/Patio Sq. Ft.
# of Full:  
# of Half:  
Sq. Ft.:  
Screened Patio:  

# of Chimneys:  
# of Hearths:  

Additional Features
Heating System
Gas Shutoff Valve
Central Air
Central Vac
Security Alarm
Fire Alarm
Smoke Detector

Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have
additional information where there was not enough space, please enter them here.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.


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