Palm Beach Insurance Group, Inc. - Peace Of Mind. Palm Beach Style.

LET US QUOTE YOUR HOME INSURANCE!

Please note that this form is a PRICE QUOTE REQUEST ONLY. Filling out and submitting this form DOES NOT bind coverage in any way. The only way coverage can be bound is when an agent of Palm Beach Insurance Group has issued the binder or policy and then notified you that it has been issued. IF YOU DO NOT AGREE WITH THIS DISCLAIMER, DO NOT CONTINUE!

By submitting this Quote Form, you confirm that you have read and agree to the above disclaimer.

INSURED INFORMATION

First Name:*

Last Name:*

Day
Phone:*

Street Address:*

2nd Phone:

City:*

State:*

Zip:*

Email Address:*

OK to Check your Credit Score?:

DOB:* mm/dd/yy

Social Security #:*

Prior Coverage?:

Prior Company:

Expires:
mm/dd/yyyy

Reason for change:

Type of Occupancy:

Bankrupcy, Foreclosure, Reposession last 5 yrs?:*

If Yes, when?:*

HOME INFORMATION
New Purchase?:*	Closing Date:		Purchase Price:		Escrow:
Yr Home Built:*	...If over 20 years old, need proof of updates!
Type of Construction:*			Foundation:*
Roof Material:*		Type of Roof:*			Roof Updated, when?:*	(If not updated, please enter 0)
Type of Heat:*		Fireplace/Woodburn Stove?:*			Heat Updated, when?:*	(If not updated, please enter 0)
Electric Updated?:	If so, when?:		Plumbing Updated?:		If so, when?:
Square Footage:*	Number of Stories:*			No. of Families Living at Home:*
No. of Bedrooms:*	Number of Bathrooms:*			Garage Description:
Screened Porch Size:			Enclosed Porch Size:
Pool?:*	Pool Fence:		Screened?:		Diving Board?:
Pets?:*	Type of Pet(s):			Breed:
Trampoline on Premises?:*			Business on Premises?:*
Protective Devices:
Smoke Detector:*	Fire Ext.:*		DeadBolt Locks:*		Alarm System:
Fire Hydrant within 1000 Ft?:*			Distance to Nearest Fire Station:*
Which Fire Station?:*			PC Class

COVERAGE AMOUNTS
Dwelling:* $		Other Structures: $
Contents(70% of Dwelling Amt.):* $		Loss of Use(20% of Dwelling Amt.): $
Liability:* $	Medical:* $		Ded. Hurricane(2% of Dwelling Amt.): $

OPTIONAL
Items to Schedule ( Appraisals Required)
Jewelry: $	Silverware: $	Guns: $	Furs: $
Do you Own any Watercraft?:*		If so, do you have Watercraft Libility coverage?:*
OTHER
Do you need Flood Insurance?*

Click Here to Clear This Form	Click Here to Email This Form to Us!

If you do not hear from us in a reasonable amount of time, it means we did NOT receive this request for a quote, so please call our office at (561) 624-0361.
Thank you for allowing us the opportunity to serve you!

To discuss your home & valuables coverage needs, please contact Mark Saccal at (561) 624-0361 or email us at info@palmbeachinsgroup.com

Need Help?

Call 561.624.0361,
email us at: info@
palmbeachinsgroup.com,
or visit us at:
13700 U.S. Highway One,
Suite 102
Juno Beach, FL 33408

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