Homeowner's Quote

To receive a Quote for Homeowner's Insurance, please fill out the following form and click the "Request Quote" button at the bottom of the form to submit your information to John J. Prudente Agency.  One of our agents will contact you shortly.

You may use your tab key or your mouse to move through the form.

Contact Information
Name:
Mail Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Email Address:
Fax: 
What is your preferred form of contact to receive your quote?


If phone, best time to call:

I Would Like A Competitive Quote
Based on my CURRENT POLICY which expires: 


Insurance Carrier:
For a NEW HOME PURCHASE, tentative closing date:

Purchase Price $:


Mortgage Amount $:

Desired Coverages
A. Dwelling: 
C. Personal Property:
E. Personal Liability:
F. Medical Payments:

Personal Umbrella Liability:

How many vehicles?

Deductible:


Prior Losses in the last 3 years:  (please describe-- loss type, date & amount paid):
 
Information About Your Home
Location of House:

if different than address above
Year Built:
Number of Units:
Number of Stories:
Square feet of Living Space
excluding basement:

Construction:
Type of Roof:

Roof Last Replaced:
(year)

Kitchens & Baths updated in last 25 years?
Yes No

Kitchens & Baths Last Updated:
(year)
Electrical System:

Electrical System Last Update:
(year)

Heating:


Heating Last Update:
(year)

If oil, is tank in the basement?
Yes No

Swimming Pool:
Yes No

If yes, is pool fenced?
Yes No
Garage:
Do you own a dog?
Yes No

If yes, what kind of dog?

Home Use:
Primary 
Secondary
Home office exposure?
Yes No

If yes, list occupation:
Owner Occupied:
Yes  No


Non-Smokers:
Yes  No

Alarm Systems:
Central Burglar
Central Fire

Monitored by Central Station?
Yes No

Safety Systems:
Smoke Detector
Deadbolts
Fire extinguishers
Sprinklers

Account Credit Eligibility

What company insures your MA Auto?

Renewal Date:


 
Is application complete and ready to submit? 
Yes

Agency | Locations | Auto | Home/Condo 
Life | Business | Claims | Quotes | Other Services | Home


Copyright 2003 JOHN J. PRUDENTE AGENCY