Golden Rule Insurance, Osage Beach, MO

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Questions? E-mail Us At:
gary@godlenruleinsurance.com

Homeowners Insurance Quotation Form Your Personal Data:

Your Name:
Property Address:
City:
Your "County" is?
*State:
Zip/Postal:
E-Mail (REQUIRED):
Phone:
Fax (optional):


Dwelling Information

Year Home Built:
Home Square footage:

Is this Builder's Risk? (new home constr.)	NO YES

Month/Year home to be complete:

Number of units:	1 family Duplex

Type foundation:	Slab Crawlspace over slab Pier & Post Other (list in remarks)

Type Roof:	Shingle Wood Shake Tar/Gravel Spanish Tile Metal Other

Number of stories:	One 1.5 Two Three

Do you own animals or pets?	Yes No
If yes, list type/for dogs, list breed:

Do You Have a Swimming pool or trampoline? (If yes, describe type and security in comments)	Yes No

# of feet to nearest fire hydrant:	# of miles to nearest fire station:

Currently Insured?	Yes No
Name of Carrier & how long insured?

Prior Claims?	Yes No
Describe claims in detail:

Rate Your Credit History and Past Insurance Payment History: (Some companies products are based on your credit and payment history.)	Excellent Fair Poor Horrible

Plumbing type:	Copper Galvanized Mixed (Copper/Galvanized)

Circuit Breakers or fuses?	Breakers Fuses

# Bedrooms: # Bathrooms:

# Fireplaces: # Chimneys:

Special features
(i.e., deck, air conditioning, alarm systems, pool, etc.)

Coverages:

Dwelling Cov. $ Contents $

Liability Cov. $ Deductible $
($250, $500, $1,000, etc.)

Comments/Remarks
(describe any scheduled jewelry, in-home business, or other special coverages needed here):

Send my quotation via: E-Mail Fax
Regular Mail
Call Me By Phone

Thank you for filling out this form COMPLETELY!
We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

Yes, I Agree. Please Send Me a Quote NOW!
*Golden Rule Insurance is licensed to sell insurance in many states. If you are contacting us from a state in which we are not licensed, we will contact you to inform you that we cannot provide you with a quote.

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Golden Rule Insurance Agency, Inc. - PO Box 810, 4065 Hwy 54, Suite One - Osage Beach, MO 65065 -

Phone# 888-635-4668 or 573-348-1731 - Fax# 573-348-5630 Terms of Use/Privacy Notice -� 2007