Home Insurance Quote Request Form

1 989 883 3240

Please use this form to request a home insurance quotation from the Kauffold Agency. By completing this form as accurately and completely as possible, you will help us to deliver to you our best possible premium. (*required fields)

1. Personal Information:

 

*First Name: Last Name: M.I.

Date of Birth Month Year

*Home Address:

*City: *State: *Zip:

Home Phone: *Email Address:

Occupation: Place of Employment:

any smokers in household? Yes No

2. Home Info Yes No Current Insurance company name:

Policy expires: Insurable value: Year built:

Construction: Deductible: Liability limit:

Describe all claims in the past 3 year, including date and amount paid. (Type "NONE" if no claims made).

  
 
 
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