Homeowners Insurance Quote Form

Servicing Home Insurance in MASSACHUSETTS ONLY 

Please complete the following form and click the "Send Quote" button to submit for a free Homeowners quote. Quote is subject to verification of information and inspection. Additional information may be requested.

**Disclaimer- Please note, these quotes are computed to the best of our ability with the information provided. If the information provided is incomplete or incorrect, your actual quote may change. Thank You.

City State Zip
Phone Fax

Home Description

Construction Brick Frame
Year Built
Please advise the date the following items have been updated if home is over 20 years old:
Is your home within 3 miles from a Fire Station? Yes No
Is your home within 500 feet from a Fire Hydrant? Yes No
Do you have smoke detectors? Yes No
Do you have fire extinguishers? Yes No
Do you want replacement cost coverage on your contents? Yes No
Are you a non-smoker? Yes No
If you own autos, would you be interested in combining the autos with the homeowners policy for additional discounts? Yes No

Coverage Limits

List any items which you desire to have scheduled for an agreed amount , i.e. Jewelry, Furs, Silverware:

General Information

Have you had any homeowner claims or losses within the last 3 years? If so, please explain:
Do you have a swimming pool? Yes No
If so, is the pool completely fenced in? Yes No
Current policy expiration date?

Any Additional Comments:

[John T Burns Insurance - Home]
QuikStart.com - design, hosting, e-commerce
© Copyright, 2010 by John T. Burns Insurance Agency, Inc. All Rights Reserved.