Home / Renters Quote Danielle M. Ellis: Customer Relations 5949 Sissonville Drive Charleston, WV 25312 Phone: 304-984-3004 Fax: 304-984-2101 Email: danielle@insurewithellis.com Text: 304-552-3004 Name Phone Email What type of home do you have? Stick Built Mobile Home If Mobile Home, is it a double wide or a single wide? Double Single If mobile home, does it have metal skirting or cinder block foundation? Metal Block Is your home frame or brick/masonry (at least 2/3)? Frame Brick Is this your first home purchase? Yes No How long have you had your current insurance? > 6 months < 6 months What is the current insured value of your house? What insurance company currently writes your home owners insurance? Do you currently have coverage for any specific scheduled personal property (ex. guns, jewelry, furs)? No Yes How much? What is your current deductible? How far is your house from the responding fire department and what is the name of that fire department? Distance mi. Name FD How far is your house from the nearest fire hydrant? ft. What is your birth date? What is your social security number? - - Are you married? Yes No Spouse name Spouse birthday Spouse SSN - - Have you or your spouse filed for bankruptcy in the last 5 years? Yes No What is your home's physical address? Address Address 2 City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Same as physical What is your mailing address? (if different from above) Address Address 2 City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Have you had any losses on home insurance in the last 5 years? If yes, give dates and description. List approximate dates and details of the incident(s) or put N/A if none What are all the types of heat you use? Electric Furnace Gas Furnace Wood Stove Baseboard Other… Enter other… You may select more than one. What is the primary source of heat? Electric Furnace Gas Furnace Wood Stove Baseboard Other… Enter other… How many square feet is your house? Approximately how many acres of land do you have? Do you have any pets? Yes No What kind? Has your pet ever bitten anyone? Yes No Do you have a swimming pool? Do You have a swimming pool? Yes No Is pool fenced? Yes No Is there a diving board Yes No How old is the roof on your house? yrs. How many fire places do you have? How many chimneys do you have? What type of plumbing? (ex. copper, PVC, rubber, galvanized) Copper PVC Rubber Galvanized Other… Enter other… You may chose more than one. What limit of liability insurance are you requesting? 300k 500k 1 million (at least 300k recommended) How would you prefer to be contacted? Phone Email Text Message Whom can we thank for referring you? We will send your quote back to you very soon! Thank you for allowing us the opportunity to serve you. We value our customers and promise to take care of you! Get an auto quote Notes to Agent