Homeowners Quote Request

Contact Information

First name:
M.I. :
Last name:
Mailing Address:
State: Available in KY,OH,and WV
Zip Code: -
Daytime Phone # : - -
Evening Phone # : - -
E-Mail Address:
Current policy
expiration date:
/ /

Location Information (Section A)

Please complete this section if the address of the property you are requesting a quote for is different than your contact information.

Street Address:
              State: Only available in KY,OH,and WV
         Zip Code: -

Location Information (Section B)

Is the dwelling located within:

1000 feet of a fire hydrant?                           Yes No
5 road miles of a responding fire station?      Yes No
Check here if this dwelling is a Condominium

Occupancy and Structure Information
Please tell us about the occupants and structure of this dwelling.


Number of families                      
Who lives in the dwelling?           
What part of the year is              
the dwelling occupied?
Is business conducted on           Yes No
the premises?
      If “Yes” what type?              
How many losses or claims       
have you experienced in the last 5 years?


Do you have a dog? Yes No
Do you have any livestock or exotic pets? Yes No
If so, what breed?
Do you have a swimming pool on the premises? Yes No
Do you have a wood, oil, or kerosene stove? Yes No
Do you have a trampoline on the premises? Yes No
Burglar alarm Yes No
Sprinkler system Yes No
Year built (Please enter a four-digit date) YYYY
Number of stories
How would you describe the road or street access to your home?

Supplemental Information

Replacement Cost:
Please enter you home's replacement cost. This is the cost of rebuilding your home at today's prices, not the sale price.

Enter the replacement cost for you home in the field to the right.

Tip: You may want to use the amount listed under “Coverage A” on your current homeowners policy.

Do you have any valuable possessions for which you would like to request coverage?

Yes No
More about your home:
Plumbing System
How long ago was your plumbing replaced?
Was all the plumbing in the interior of the home replaced? Yes No
What is your wiring type?
How long ago was your wiring updated?
Was the home completely re-wired? Yes No
Which best describes your electrical service panel?
How long ago was your roof replaced?

Discount Information

The following questions are optional. Please note that if you choose not to answer these questions, you will not be eligible for any discounts which carriers may provide.
Protective devices:
Fire Extinguishers Yes No
Smoke detectors Yes No
Fire Alarm type
Deadbolt locks Yes No

Deductible and Coverage Amounts

Please choose the desired amounts for your policy deductible and coverage limits.

Tip: If you currently have a policy, you can refer to it to select comparable coverage amounts.
Policy deductible $
Coverage A: Dwelling structure replacement $
Coverage B: Other structure replacment
Typical coverage limit: 10% of coverage A (Dwelling Structure Replacement)
Coverage C: Other structure replacment
Typical coverage limit: 50% of coverage A (Dwelling Structure Replacement)
Coverage D: Other structure replacment
Typical coverage limit: 20% of coverage A (Dwelling Structure Replacement)
Personal liability
Typical coverage limit: $300,000
Medical Payments
Typical coverage limit: $5,000

Valuable Possessions:

(select the full amount of coverage desired)

Cameras (not used professionally)
Musical Instruments (not used profesionally)
Golfer's Equipment
Fine Arts
Postage Stamps
Personal Computers and Electronic Equipment
Do you currently have insurance on this dwelling? Yes No
Desired Effective Date / /

Insurance products are underwritten by various insurance companies and are offered through Peoples  Insurance Agency, Inc., (“PIAI”), a subsidiary of Peoples Bank, National Association. The purchase of insurance from PIAI does not affect your banking business and is not required to obtain credit or services from your bank. Insurance products are not bank deposits, are not FDIC insured, nor are they guaranteed by the bank. Insurance Products are not insured by any Federal Government Agency.

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