Homeowners/Renter's Quote Form
Please fill out all sections highlighed in yellow and push the submit button when you are finished.
Name:
Address:
City:
Country:
State:
Home Telephone Number:
Work Telephone Number:
Cell Phone:
Fax Number:
Email Address:
Spouse's Name:
Social Security Number:
Date of Birth:
*mm/dd/yyyy
Homeowner or Renter?:
Number Stories:
Square Footage:
Year Built:
Construction Type:
Is this property your primary residence?
Yes No
Number of families living at this residence:
Do you have a swimming pool?
Yes No
Do you have pets or animals?
Yes No
If yes, Please state number of pets and types of pets in the household:

Are there any woodburning stoves, fireplace inserts, woodburning furnaces, space heaters, or kerosene heaters on the premises?
Yes No
Basement:
Yes No Finished Unfinished
Type of Home:
Single Twin Row Duplex
Amount of Insurance Requested
Dwelling (excluding land):
$
Personal Property:
$
Personal Liability:
Medical Payments to Others:
Please list all claims for the prior 5 years:

Has the house ever been updated for the following:
Electrical:
Yes No
Approximate Date:
Type of Electrical Service:
Fuse Circuit Breakers
Plumbing:
Yes No
Approximate Date:
Type of Heating Service:
Gas Forced Air Gas Hot Water Oil Heat
Propane Other Please List:
Year Heater Was Updated:
Roof:
Yes No
Approximate Date:
Additional Coverage Requested:
Dwelling Replacement Cost Guarantee:
Yes No
Replacement Cost Personal Property:
Yes No
Ordinance or Law Coverage:
Yes No
Earthquake Coverage:
Yes No
Umbrella Liability:
Yes No
Has any company declined, cancelled, or refused to renew any similar insurance:
Yes No
If yes, explain:

Have you ever had any loss such as fire, windstorm, theft, liability, etc. on this or any other property during the prior 5 years:
Yes No
If yes, explain:

What is the expiration date of your current policy?
How Did You Hear About Us?

Additional Comments:

How do you want to recieve your quote?
Via E-mail Fax Telephone
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Payment Info
Claim Info
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The Lowa Group, Inc. | 1104 East High Street Pottstown, PA 19464 | P: 610-327-1980 | F: 610-327-8267 | Info@lowagroup.com
8002 Germantown Avenue Philadelphia, PA 19118 | P: 215-242-2242 | F: 215-600-1835
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