Insurance agents who care about your needs

About Property Insurance Policies,

Note that your request to a Wasserman Agent will be handled on a very personal basis, we are not a business who sells leads to a list of bothersome sales people. You will only be contacted by one agent who will personally and directly help you assess your needs. You will not be added to endless mail lists like other websites who promise multiple quotes.

Please note that all information must be answered thoroughly and honestly. Attempts to withhold material facts or negligence can interfere with processing and awarding of claims. If you have questions or comments please note them in detail in the suggested field at the bottom of this form.

The Wasserman Agency, Inc. has a privacy policy to protect your personal information. Prior to issuing a policy companies may verify loss and credit history using consumer reports to determine eligibility and to provide an accurate quote. You have a right to access and correct all personal information that is collected.

Personal and contact information: This information should relate to the individual most likely filling out this form otherwise who will be responsible for managing and paying for this policy if and when it is established.

Key
Red & Bold	Required Fields
Blue & Bold	Optional but helpful
Black & Bold	Required when applicable

Name:

Date of Birth

(mm/dd/yyyy)

Spouse name*

Date of Birth*

Main Phone:

Work Phone:

Cell Phone:

email:

Best Contact Time:

Current Street Address:

City State Zip

New Home Information:
If this quotation is for a new property you are in the process of moving into, the following information is required, if you are insuring your current address, you have already entered that above.

New Home Address*

City State Zip

About the home/property insured:
For a more accurate quotation please make sure to provide all of the following information about the property being insured.

Year Built:

Dwelling Type:

Square Feet:

Roof Type :

Foundation:

Exterior Walls:

Construction:

Heating Type:

Distance to fire station:

(in miles or parts)

Distance to fire hydrant:

(in blocks, miles, or parts)

Dog:

(Note all - Breed & Any Attack History)

Pet Notes>

Security:

Fire Sprinklers

Yes or No

Deadbolts:

Yes or No

Smoke Alarms:

Yes or No

Fire Extinguisher:

Yes or No

Dwelling Amount:

Personal Contents

Personal Liability Amount:

Quote Flood Insurance?

Yes or No

Current Carrier:

Detail any and all homeowners insurance claims you have made over the past 5 years.

Claims History>

If you have any specific information you'd like to express that may or may not be material to the quotation you are seeking please provide that information here, we will be glad to address any and all of your concerns.

Details>

Terms & Conditions, please check and initialize or form will NOT process.

Please place a check mark(click on) the box to the left of this text to indicate that you understand the following terms and conditions. As the individual filling out this form you understand that this is only a request for a quotation for your property insurance policy. Submitting this form does NOT constitute or imply that you have purchased coverage from the Wasserman Agency or any of its affiliates. As the individual filling out this form you also confirm that you understand you are legally obligated to provide all information requested to the best of your ability, that all information is correct, and current to your knowledge and ability to know at the time you are submitting this form.

DISCLOSURE: Where permitted by law, some insurance companies may confirm your information, through the use of consumer reports, which may include credit score and other public or non-public records. By submitting this information, I request that the Wasserman Agency contact me via email, telephone or fax, using the information I have supplied, to provide quotes or to obtain additional information needed to provide quotes.

Initials

<< Please place your initials here.

(1). As qualified and professional insurance agents we promise to do our best to protect your interests, however, it is, of course impossible to guarantee that any insurance product will protect against all possible varieties of risk. Our commitment is to assist you in balancing your requirements and budget to provide you with the best set of insurance policies to fulfill your individual and unique needs.