Buhl Insurance Agency, Inc. - Homeowner / Flood Insurance

Homeowner / Flood Insurance

Use this form to request a quote for homeowner and/or flood insurance.
All fields are optional.
This form is not secure.

Contact Information

Name:

Street address:

City: State: Zip:

E-mail address:

Home phone:

Work phone:

Cell phone:

Pager:

Fax:

Preferred method(s) of contact:		Home phone		Cell phone		Fax
		Work phone		Pager		E-mail

Homeowner Information

I would like a quote for:	Homeowner Insurance
	Flood Insurance

Name:

Street address:

City: State: Zip:

Home is inside outside city limits of:

Construction of home:

Year of construction:

Square footage:

Year Last Re-roofed:

Wiring: Aluminum Copper

Elevation of home: feet above sea level

Number of stories:

Number of bedrooms:

Number of families:

Distance to fire hydrant: feet

Distance to nearest fire station: miles

Number of claims during past 3 years:

Name of current company:

My insurance expires on

I have: a burglar alarm a smoke alarm

Amount of coverage on home: $

Amount of coverage on personal belongings: $

My premium is paid by me or my mortgage company.