Art Hollingsworth Insurance Services
Art Hollingsworth Insurance Services

Insurance Application
  We would like to provide you with a free, no-obligation 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.

All fields below are required (unless otherwise noted) in order to submit this online application.

Agent Information
Agency Contact:    ( not required )
Company Name:  
License #:  
Phone #:  
Fax #:  

Email Address:

Broker Fee:
 $ (Cannot exceed $75)

How would you like your quote sent:
 By Fax   By Email

Client Information
Named Insured:  
2nd Named Insured:    ( not required )
At least one phone number required below:
Day Phone:  
Evening Phone:  
Email Address:  
 ( not required but VERY helpful )
Property Address
Property Street Address:  
Property City:  
Property State:     Zip:
Mailing Address
Is Mailing Address the same
as Property Address?:
 Yes No
 (If "No", please complete the remainder of this section)
Mailing Street Address:  
Mailing City:  
Mailing State:     Zip:

Dwelling Information
Occupied by:  Owner Tenant
Number of Family Units:  
Year Built:  
Living Area:   (sq. ft.)
Number of Levels:  
Type of Building:  
Construction Type:  
Foundation Type:  
Is the foundation bolted?:  Yes   No
Basement Type/Square Footage:
 Finished: (sq. ft.)
 Unfinished: (sq. ft.)
Roof Type:  
Siding Type:

Please hold down Ctrl key
to select more than one item.

Garage Type:  
Size of Garage:  
Cripple Wall Type:  
Primary Heating Source:  
Central Air?:  Yes   No
# of Full Baths:  
# of Half Baths:  
Bath Quality:

(select the # of bathrooms
with the following)

 Double Sink:  
 Bath & Shower Stall:  
Kitchen Quality:

(select from the following)

 Corian/Granite/Marble:   Yes No
 Commercial Fridge:   Yes No
 More than 1 Oven:   Yes No
 6 or more range burners:   Yes No
 Center Island:   Yes No

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

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