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NFIP

Homeowners Insurance
Quote Form

When filling out the Homeowners Insurance Quote Form below, be sure to fill in all of the Information in the Blue Sections. If you do not fill out this required information, your form will not be processed.

Mathes Insurance Group is licensed to sell insurance in the State of Iowa. If you are not a resident of the State, or if the exposure you wish to insure is not in the State, we will be unable to provide a quote. Quote indications provided by e-mail from this form are estimates only and are subject to change upon formal application and additional information obtained or revised. Please note that all information submitted will be held confidential except for submission to appropriate insurance carriers and/or representatives for the purpose of obtaining quotes. Mathes Insurance Group accepts no responsibility for electronic piracy, etc., when any information is submitted electronically. Completing and submitting the following information indicates understanding and acceptance of these terms and conditions. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

General Information

Name:

Address:

City:

  State:    ZIP:

County:

  Email:

Evening Phone:

( ) -           

Day Phone:

( ) -

Best time to call:

  am  pm

Occupation:

        How long at current job: years   months

Current Homeowners Insurance Company (not agency):

Company Name:

Policy Exp. Date:

/ /

Amount Insured For:

$

Premium:

$

Term:

6 Months   1 Year   Other  

Home Information

How long at present address:

years months

# of claims in last 3 years:

Sq. footage of home (excluding
garage and basement):

Year home was built:

Distance to Fire Department (blocks):

1 2 3
4 4+

Distance to
Fire Hydrant:
(Feet)

0-250
250-500
 500-750
 750-1000
 1000+

Structure Information

Type:

Construction:

Roof:

Age of roof:   yrs.

Foundation:

Garage:

Garage Type:

Features

Bathrooms:

Basement:

Deck/Porch/Patio:

Fireplaces:

# of Full:

Deck Sq. Ft:

# of Chimneys:

# of Half:

Sq. Ft:

Porch Sq. Ft:

# of Hearths:

Patio Sq. Ft:

Additional Features

Heating System:

Central Air:

Central Vacume:

Security Alarm:

Fire Alarm:

Smoke Detector:

yes
no 

yes
no 

yes
no 

Additional Comments:

Please give any additional comments about the coverage you desire:

 

Thank you for your time in submitting this
Homeowners Insurance Quote Form.
One of our representatives will respond to your
submission as soon as possible!

Mathes Insurance Group
120 W. State Street
Mason City, Iowa 50401		 Phone: 641-423-4663
Toll Free: 877-421-4663
E-Mail: rickmathes@rickmathes.com