Homeowners

CONTACT INFORMATION

Are you (or will you be) the owner of the home? *

Yes
No

If yes, please enter your first and last name below.

If no, please type your full name and describe your relationship to the homeowner.

First Name *

Last Name *

If you are not the homeowner, please describe your relationship to the homeowner. If you are the homeowner, type "NA." *

Mailing Address *

City *

State *

ZIP / Postal Code *

Street Address of where you currently reside (if same as mailing, type same) *

City, State & Zip where you currently reside (if same as mailing, type same) *

E-Mail Address *

Primary Phone Number *

Your Date of Birth *

/

Is there a 2nd Named Homeowner? *

Yes
No

Full name of 2nd Insured (type NONE if not applicable) *

Date of Birth of 2nd Homeowner. If no 2nd Homeowner, type NA. *

HOME INFORMATION

Is this insurance quote for your current home or a new purchase? *

If New Purchase, What is the Purchase Price? If Not New Purchase, Type "NA." *

Address for New Home Purchase or Your Current Home Address *

City, State, & Zip for New Home Purchase or Current Home *

Year Built *

Use of Home *

Construction Type *

Frame
Brick
Not sure

Roof Type *

Asphalt
Metal
Architectural Shingles

Age of roof *

# of Stories *

Built on Slab? *

Yes
No

Does the home have a basement? *

Yes
No

Estimated Sq. Footage of home (excluding basement) *

Square footage of Basement. If no Basement, Type "NA." *

What is the percentage of finished basement? If no basement, type "NA" *

Type of Garage *

None
Attached
Attached with room above
Detached
Detached with apartment above

Type of Heating Unit *

Electric
Gas
Other

Any Updates to Home? *

None
Electrical
Plumbing
Heating

Number of families living in home? *

Dogs *

Pool *

If YES, does pool have a slide or diving board? *

Yes
No
No Pool

Do you have a trampoline? *

Yes
No

Do you have a monitored alarm system? *

Yes
No

CURRENT INSURANCE INFORMATION (Complete this section only if you currently have Homeowners Insurance)

Current Insurance Provider - if None, Type "None." *

How much is your home currently insured for $: *

Have you had any claims/property losses in last 5 years? *

Yes
No
Not Sure

If YES, please provide brief description of claim and include the year. If no, type "NA" *

PLEASE LET US KNOW

How did you hear about us? Please let us know *

Internet Search
Ga Indep Auto Dealer Assoc (GIADA)
Mailing from D. Ward
E-Learning Concepts Dealer Training
A Friend
Other

If you selected "Friend," please enter the friend's name here. *

If you selected "Other," tell us how you heard about us. *

Is there anything else that you would like for us to know concerning your up and coming Renewal?

SIGNATURE REQUIRED

I have provided all of the above information for insurance purposes and I state all information is true to the best of my knowledge. I also understand that I am to discuss with the agent at D. Ward Insurance my desired limits and coverage.

By typing my name warrants my signature. *

ADDITIONAL INFORMATION NEEDED

After you have sumitted your quote request, we will start working on your quote and we will help assist with obtaining your claim history. The insurance carriers require us to show prior proof of coverage along with claim history.

Thank you for your time and we will be in touch with you today unless this is after hours or on the weekend.

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Auto
&
Home

Life
& Disability

Restaurant & Liquor

Garage & Dealership

Business & All Other

Umbrella

Homeowners

Questions to Ask About Home Insurance:

Contact Us Today!
770-974-0670

Resources

Contact Us

Auto & Home

Life & Disability

Restaurant & Liquor

Garage & Dealership

Business & All Other

Umbrella

Homeowners

Questions to Ask About Home Insurance:

Contact Us Today! 770-974-0670

Resources

Contact Us

Auto
&
Home

Life
& Disability

Contact Us Today!
770-974-0670