Request for Information

Request for Information
Please complete the following form and click Quote It! We will contact you as soon as possible regarding your request.

All information is necessary for a quote. If you live at a rural route or post office box number, please provide us with driving directions to your home.
Date
 Current Insurance Company
First Name
 Last Name
Street Address
 City
 State
 		Zip Code
Contact Phone
 E-mail Address
 How did you hear about us?
Social Security Number
 Date of Birth
 Spouse SSN
 Spouse DOB
Construction
Frame    Masonry    Mobile Home   
Year, Make, Model and Dimensions of Mobile Home
Is it on a permanent and continuous masonry foundation?
Coverage Amount
 Purchase Price
 Deductible
Do you need Coal Mine Subsidence?
Yes    No   
Any Acreage?
If yes, how many acres and are you farming it?
Do you own any dogs?
Yes    No   
What breed?
If a mix, what breeds?
 Ever bitten anyone?
Yes    No   
Distance to Fire Department?
Distance to Fire Hydrant? (in feet)
 Responding Fire Department?
Do you own a swimming pool or trampoline?
Yes    No   
If so, is the pool...
Fenced In    Inground   
Year of Construction
 Age of Roof?
 Age of Heating?
 Age of Plumbing?
 Age of Electrical?
Type of Heat?
 		Do you own a wood or coal stove?
Yes    No   
Fireplace?
Square feet of living area?
 How many stories?
 		Number of Bathrooms?
Garage? How many stalls? Attached or Unattached?
 Basement? Finished or Unfinished?
Do you own any boats, ATVs or motorcycles?
Yes    No   
If so, what?
Have you had any claims in the last 5 years?
Yes    No   
If so, what?
Any business conducted on the premises?
Yes    No   
If so, what?
Directions and Comments




Aliff Family Insurance, Inc.

   Home    Services    Home Quote!    Auto Quote!    Location


This site is best viewed with Macromedia Flash.
Click here to view site without Flash.



Sign In