Full Name:

Street Address:

City, State, Zip

Telephone:

Email Address:

Years at Current Address:

General Information

Current Carrier Information

Current Insurance Carrier

(not agent/broker):

Policy Expiration Date (mm/dd/yyyy):

Premium:

Term of Policy:

Have you had any claims, whether paid or not by insurance, in the past 3 years at this location?

Description of Loss:

Amount Paid:

Date:

**Information received from this quote request form sent to A.L.S. Advisors, Inc. will be for

our use only and will not be sold or distributed to any other parties. By submitting

this request you acknowledge that this is neither an offer to insure nor a guarantee of

Insurance. No coverage is bound or implied by submitting this information.

Coverage Requested for:

Usage Type:

Years at Address to be Quoted:

Dwelling Information

Dwelling Value ($)

Additional Structure Value ($)

Personal Property Value ($)

Personal Liability Limit:

Medical Payments Limit:

Deductible:

Construction:

Year Built:

Square Feet:

Heat Type:

Fireplace:

Full Baths:

Half Baths:

Garage:

Basement:

Roof Age:

Pool:

Diving Board:

Approved Fence:

Dwelling Occ. By:

Loss History

If yes, please provide detail below:

Additional Comments or Questions:

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