Insurance Quick Quote Indication Questionnaire

Condo − Dwelling & Fire

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Please complete all fields unless marked optional. If you have any questions, please call us at the number above.

Your Name:
Property Address:
Property Address continued:
Property City:	State: Zip Code:
Email Address:
Contact Phone:

Information About Your Home

Date Needed:	(Renewal Date / Escrow Closing / Etc.)
Year Built:	Number of Stories: Square Feet:
Type of Roof:	(Wood Shingle / Composite / etc.)
Number of Bathrooms:	Number of Fireplaces:
Is there is a Garage?	Attached Detached No Garage
Type of Pets:	(Dogs / Cats / Horses / etc)

Comments, Priority, Terms of Use

Comments or Additional Info:

Please Prioritize Your Request:	Hurry! I need it ASAP! Please quote prior to my renewal No hurry, just checking

By submitting this quick quote application, you declare that the information you are providing is accurate and complete to the best of your knowledge and belief. AMIS/Alliance Marketing & Insurance Services does not warrant or guarantee suitability or adequacy of coverage in meeting any generic, specific or contractual requirements of any insurance company, state, county, corporation, public entity, or public party that you may provide services to during the policy period, including any written or oral request forwarded to AMIS or its staff. You assume the risk of obtaining suitable or adequate coverage to meet any generic, specific or contractual requirements of your client or company. The information contained herein is provided with the understanding the AMIS is not engaged in rendering legal services, including legal opinions or advice, or professional risk management consulting. If legal services or professional services are required, you will need to seek the advice of legal counsel.

You agree:	Yes NoNOTE: This constitutes a digital signature.

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NOTE: An application or information form is not an insurance policy and does not bind any coverage. All applications must be underwritten and a quotation will be issued subject to underwriting guidelines. The quotation does not bind coverage.