Jon Decker Homeowners Quoting Tool

Full Name

Residence Address

City

State

Zip Code

Email address

Phone

SSN

Full Name(Additional Insured)

SSN

DOB

Time at Present Address(Yrs)

Current Insurance Carrier

Expiration Date

Previous Address(Address, City, State)

Mailing Address(Address, City, State)

If quoting for a new home please input expected values.

(Renters only input Personal Property and Liability)

Current Homeowners Insurance(If applicable)

Expiration Date

Current Dwelling Replacement Value

Current Person Property Value

Current Liability Coverage

Medical Payments

Bathrooms(Check 1/2 to add to number)

1 Bath

2 Bath

3 or More

1/2 Bath

Square Footage(Do not include finished Basement)

Year Built

Year Electric Was Updated

Year Plumbing Was Updated

Coverages Requested

Back Up of Sewer/Drain

Incidental Business

Cyber Theft/Fraud

Increased Valuables

Discounts (Please select all that apply)

Smoke Detector

Fire Extinguisher

Burglar Alarm

Centrally Monitored Alarms

Local Access to Water <500Ft(Pond, River, Stream)

Access

No Access

Roof Replacement Date

Garage Type

Attached

Detached

Basement

Walkout

25% Finished

50% Finished

75% Finished

100% Finished

Basement Garage

Interior Finish Quality

Standard

Builders Grade

Upgraded

Custom

Notes

Please note that all information is confidential and will only be used by Jon Decker Insurance. By submitting this form you agree to be contacted by Jon Decker Insurance.

You may upload any current declarations pages below to make sure your quotes match existing coverages.

Contact Preference(Please select all that apply) Data will only be used by Jon Decker Insurance

Phone

Text

Mail

Files

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