Homeowners Quote

3748 Oakton Street

Skokie, IL 60076

1-877-447-6646

(1-877-4IRMOINS)

Irmo Insurance Agency, Inc.

Licensed in Illinois, Indiana,

Kentucky, New York

Pennsylvania & Wisconsin

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Need a quote for homeowners insurance? Please complete the form below and click submit to send it to Irmo Insurance Agency, Inc. If you have any questions while completing this form, please email us at office@irmoinsurance.com or call us at 847-677-0505.

Home/Mobile Home Owner Quote

No coverage is bound until you are contacted by one of our representatives

CONTACT INFORMATION

Name
Street Address
Current Mailing Address
City, State, Zip
Email Address
Social Security #
Date of birth
Occupation
Employer
How long with current Employer
Phone Number	Home Work

SPOUSE INFORMATION

Social Security #
Date of birth
Occupation
Employer
Phone Number	Work

HOME TO BE INSURED

Street Address
Street Address
City, State, Zip
How long at present address
Previous home address if less than 3 years at present address

IF MOBILE HOME

a. Do you own or rent the land
b. Is mobile home in a park?	If yes, park name
c. Mobile home Width & Length
d. Manufacturer Name
e. Model Name
f. Year Built
g. Serial Number

RATING INFORMATION

1. What year was this home built?
2. What type of construction was used?
3. Number of Stories
4. Other Occupancies:
5. Age of Roof
6. Roof Type	If Other
7. What style is your home?
8. How will your home be used?
9. How many rooms in your home?
10. How many full bathrooms in your home?
11. How many 3/4 bathrooms in your home?
12. How many 1/2 bathrooms in your home?
13. How many square feet on the first floor?
14. What type of home do you have?
15. How many total square feet in your home?
16. Do you have a fireplace?
If yes, please describe what type
17. Do you have a woodstove?
If yes, please describe type and use
18. Do you have a garage?

If yes, please describe what type
19. What is your primary source of heat?
20. What is your secondary source of heat?

PROTECTIVE DEVICES:

21. Do you have a security system?
If yes, please describe what type
Burgler Alarm
Type of Alarm
Alarm Company
Sprinkler System In Building
Smoke Detectors
22. Have you had any losses in the past 3 years?
If yes, please describe
23. Is this your first home?
If no, do you have current insurance?

24. Do you own any pets?

If yes, Please describe

25. Any Hot Tub, Sauna, Swimming Pool, Trampoline, wet Bar, Etc.?

If yes, Please describe

26. Any updates that have been done on home,
(i.e., new roof, electrical, heating, retrofitting, etc).

If yes, Please enter date complete and describe

IF THE BUILDING IS OVER 25 YEARS OLD, PLEASE ANSWER THE FOLLOWING:

27. Year Electricity was Updated
28. Is it on Circuit Breakers
29. Year Plumbiing was Updated
30. Copper or Galvanized Plumbing	If Other

CURRENT INSURANCE

1. Previous Carrier
2. Start date	End Date
3. How Long Insured
4. Amount insured for
5. Policy Number
6. Prior Premium $
7. Policy Renewal Date

COVERAGE INFORMATION

1. Dwelling
2. Contents
3. Liability
4. Medical Coverage
5. Deductibles
All Perils
Wind/Hail/Storm
6. Loss of Use

ADDITIONAL INSURED

Name
Address
Phone Number	Phone FAX
Account or Loan #

LIEN HOLDER

Name
Address
Phone #
Fax #
Loan #
Mortgage Clause
Legal description

Please use the space below to add comments regarding any special circumstances or coverage needs

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