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.

* All Relative Fields Are Required

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

  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 First Name:   Applicant Last Name:
Applicant Date of Birth:   Applicant Gender: Male Female
Marital Status:   Occupation:
Is there a Co-Applicant?:
Property Address:
City:   State:   Zip:
In City Limits?:
Mailing Address same as Property Address?:
Prior Address:
(If at Property Address less than 2 years)
City:   State:   Zip:
Email Address:
Has property insurance been cancelled,
declined or non-renewed in last 5 years?:

Current Homeowners Insurance Information
Do you currently have Homeowner's Insurance?:

New Coverage Information
Amount of Coverage Desired: $
Desired Deductible: $
Personal Liability: $
Earthquake Coverage:
Extended Coverage: $

Home Information
Date Applicant Purchased Property:     Year Home Was Built:
Swimming Pool?:        
Any Pets?:
Sq. Footage:
(excl. garage/basement)
sq. ft.       # of Units:
Miles to Responding Fire Dept.:     Feet to Fire Hydrant:
Is home more than 20 years old?:

Structure Information
Exterior Walls
Age of roof: yrs.

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

# of Chimneys:  
# of Hearths:  

Additional Features
Heating System
Gas Shutoff Valve
Central Air
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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