HOMEOWNER'S/MOBILE HOME OWNER'S ONLINE QUOTE
Please fill out the form below and submit it or print it and fax it to us at (386) 325-3575.
We will respond back promptly.
Thank you for your interest in Accord Insurance Network.

Contact Information:
Name:
Street Address:
State:
Zip Code:
Work Phone:
Home phone:
Fax:
E-mail:

Occupation:
Self:	Spouse:
Construction:
Frame.  If frame, foundation is: Open Closed
Brick, stone, or masonry.
Brick, stone, or masonry veneer.

Primary heat source:
Carport or garage:
Year built:
Make and model: (for mobile homes only)
Skirting: (for mobile homes only)	Yes No
Front and rear handrails on steps: (for mobile homes only)	Yes No
Length: (for mobile homes only)
Width: (for mobile homes only)
Square footage:
Amount of coverage requested:
If tenant, amount of personal property coverage requested:
Number of baths:
Fireplace:	Yes No

Protective Devices - Check those which apply
Smoke or Fire Detector
Fire Extinguisher
Monitored Burglar Alarm
Dead Bolt Locks
Monitored Fire Alarm

Is there a swimming pool on the premises?	Yes No
If yes, is it fenced?	Yes No
Do you own a dog ?	Yes No
If yes, name of breed.
List all losses for the past three years.

If home is over 35 years old, please fill in the dates of renovations for:
Wiring:
Plumbing:
Heating:
Roofing:
Comments/Questions/Description:

ACCORD INSURANCE NETWORK
(Corner of St. Johns & Palm Avenue)
100 Palm Avenue • Palatka, FL 32177
(386) 325-3255 • Fax (386) 325-3575
Email: J4ins@bellsouth.net

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