request a free homeowners policy quote
from
Ed Janik Insurance
Your Name
*
:
E-Mail
*
:
* indicates field is required
Primary Phone
*
:
Secondary Phone or Fax:
please indicate in
the comments section
below which method and at what time you wish to be contacted
Information pertaining to the home you wish to insure:
Street address:
City:
State:
ZIP Code:
Year Built:
SQUARE FOOTAGE:
no commas, only digits
Age of Homeowner
Non-Smoker:
Smoker:
Structure Type:
select Structure
frame/stucco
wood
brick
Garage:
select garage type
none
Detached - 1 car
Detached - 2 car
Detached - 3 car
Attached - 1 car
Attached - 2 car
Attached - 3 car
Builtin - 1 car
Builtin - 2 car
Builtin - 3 car
Roof Type:
select roof type
wood shingle or shake
tile
composition
Stories:
select stories
1
2
3
4
over 4 stories
Bath rooms:
select baths
1
1.5
2
2.5
3
3.5
4
4.5
5
5.5
6
over 6 baths
Fireplaces:
select # of fireplaces
1
2
3
4
5
6
over 6 fireplaces
ALARMS:
Fire
Burglar
Central
Comments
*
:
(such as time to call, preferred phone or email contact, special needs in your policy or traits of your home, etc)
* indicates field is required
*
original Script Created by:
Matt Wright
.
website and script modifications by
Harry Abramowski