Morris Real Estate & Leesville/Ft. Polk

Much of the information requested is directly used in calculating your quote. The more information
provided, the more accurate the quote.

By submitting this information I verify that I understand that no coverage is bound or placed in effect.
Homeowners Insurance Quote Form

General Information

Name:

Address:

City: State: Zip:

Parish: Email:

Phone Day: Night:

Best Time to Call: AM PM

Occupation:

Time at current job: Years Months

Current Homeowners Insurance Company (not agency):

Company Name:

Policy Exp. Date:

Amount Insured For: $ Deductible:

Premium:$

Do you have replacement cost on coverage contents?: Yes No

Home Information

How long at present address:

years months

# of claims in last 3 years:

Sq. footage of home
(excluding garage and basement): Year home was built:

Structure Information

Type: Foundation: Construction:

Garage:
Roof:
Age of roof: yrs.

Features

Bathrooms: Basement: Deck/Porch/Patio: Fireplaces:

# of Full:
# of Half:
sq.ft. Deck: sq.ft.
Porch sq.ft.
Screened Patio: sq.ft. # of Chimneys:
# of Hearths:

Additional Features

Heating System: Central Air: Central Vac:

Security Alarm: Fire Alarm: Smoke Detector: Dead Bolt Locks: Fire Extinguisher: Non-Smoker:

yes
no yes
no yes
no yes
no yes
no yes
no

Additional Comments
Please give any additional comments about the coverage you desire:

By submitting this information I verify that I understand that no coverage is bound or placed in effect.

Contact Us

General Information
Name:
Address:
City:	State: Zip:
Parish:	Email:
Phone Day:	Night:
Best Time to Call:	AM PM
Occupation:
Time at current job:	Years Months

Current Homeowners Insurance Company (not agency):
Company Name:
Policy Exp. Date:
Amount Insured For: $	Deductible:
Premium:$
Do you have replacement cost on coverage contents?: Yes No

Home Information
How long at present address:
years months
# of claims in last 3 years:
Sq. footage of home (excluding garage and basement):	Year home was built:

Structure Information
Type:	Foundation:	Construction:
Garage:	Roof: Age of roof: yrs.

Bathrooms:	Basement:	Deck/Porch/Patio:	Fireplaces:
# of Full: # of Half:	sq.ft.	Deck: sq.ft. Porch sq.ft. Screened Patio: sq.ft.	# of Chimneys: # of Hearths:

Additional Features
Heating System:	Central Air:	Central Vac:

Security Alarm:	Fire Alarm:	Smoke Detector:	Dead Bolt Locks:	Fire Extinguisher:	Non-Smoker:
yes no	yes no	yes no	yes no	yes no	yes no

Additional Comments Please give any additional comments about the coverage you desire: