Quotation Request Form for Homeowners Insurance

Reynolds & Reynolds Insurance Agency

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Your Name

Social Security #


Home Phone

Work Phone

Reason for Quote:  
Buying New Home Closing Date
Cancelled by Prior Insurance Company


Not Happy with Present Insurance Company




Please list all claims within the past 5 years. 

Include the Date and reason for the claim, and the amount paid.


Past Claims

Property to be Insured:


Address 1

Address 2



Year Dwelling was Built
  Frame   Brick
  1 Family   
  2 Family

How many:

within 2500 Feet of coastal water
 Feet from Fire Hydrant?
Miles from Fire Department?

Coverage to be quoted


Amount of Fire Insurance


Full Replacement Cost on All Contents


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All quotes will be provided with the following:


$500 deductible

  Form 3 Deluxe Homeowners Package
  Replacement Cost on Dwellings
  Additional Living Expenses
  Medical Payments

Other coverage, choices, and riders are available and can be discussed upon request.