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Homeowners Insurance Quote Request
To receive a free home owners insurance quote from the Perrine Agency, answer the following questions and submit.  An agent will analyze your information and contact you shortly.  You may also print out this page, fill in at your convenience, and fax to us at (952) 888-1134.

 YOUR INFORMATION
 
  First Name
 
  Middle Name
 
  Last Name
 
  Street Address
 
  City
 
  State
 
  Zip Code
 
  Phone (Work) - include area code and extension
 
  Phone (Home) - include area code
 
  Email Address
 
  Date of Birth (month/ day/ year)
 
  Occupation
Yes    No  -   Do You Currently Have Homeowners Insurance?

 If yes, who is your current insurance company? 
 If yes, when does your current policy expire?    
 If yes, how much is your home insured for?      
  Year You Purchased Your Home
 $ Purchase Price
 $   Loan Amount
  Interior Square Footage(approx.)
  Year Built
 
 Select Yes or No for the Below Questions:
 1. Is your home located on a hillside? Yes No
 2. Home located within 500 ft of a fire hydrant? Yes No
 3. Is there a fire station within 5 miles? Yes No
 4. Home susceptible to flooding or high water? Yes No
 5. Area prone to sinkholes or landslides? Yes No
 6. Home located within a brush hazard area? Yes No
 7. Do you have pets? Yes No
 8. Firearms in house? Yes No
 9. Central alarm system in house? Yes No
 10. Have you had any claims or losses within the past 5 years? Yes No
 11. Do you have a basement? Yes No
 12. Do you have a pool? Yes No
 13. Do you have a garage? Yes No
 HOUSE INFORMATION
 
  Number of Stories
 
  Number of Residents Living in House
 
  Number of Rooms
 
  Number of Bathrooms
 
  Number of Fireplaces
 
  Type of Exterior Wall
 
  Roof Type and Year New
 
  Foundation Type (eg. walk out, slab, crawl space)
 

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"Don was able to find us the best package to meet our needs at the best price and provided friendly, personal service.  Glad we found you!"

Kevin & Jill Unterreiner
Eden Prairie, MN