Homeowners Insurance Quote Form

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.


 
Name
Address 
 
City State Zip
County
 
Phone Fax
 
E-Mail

Home Description

Construction  Brick  Frame 
 
Year Built 
Please advise the date the following items have been updated if home is over 20 years old:
 
Plumbing
Heating 
Electrical 
Roof 
 
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

Dwelling
Contents 
Liability
 
Deductible
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: 


 
Send comments and questions to info@keoughkirby.com
Keough Kirby Insurance Agency, Inc.
Tel: (401)769-8100
Fax: (401)766-4973
Toll Free: (800)825-8765

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