Low cost New Hampshire insurance from Immanuel Insurance Agency
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Homeowners Insurance
Quotation Form
One Simple Form - takes only 2-3 Minutes!


Your Personal Data:
 
Your Name:
Property Address:
City:
Your "County" is?
State: (Must be New Hampshire)
Zip/Postal:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
 
OPT-OUT SELECTION: We realize your time is valuable. Rather than fill in all the underwriting information below, would it be easier to have us call you? If so, you can check the "Opt-Out" box above, press the send button at the bottom of this form, and have a friendly agent call you. If possible, please have your current policy handy as this has helpful information we may need.

If you want to continue the complete online quoting process, do NOT check the box and please continue below.

Primary Insured's Occupation:
Company Sponsor for group discount, if any:
 
Primary Policyholder's Birthdate:
(REQUIRED - Some companies products
offer discounts for certain age groups.)
 
 
Dwelling Information
 
Date Home Purchased:
Year Home Built:
Home Square footage:
 
Occupancy Type:
 
Is this Builder's Risk?
(new home constr.)
NO YES
 
Month/Year home
to be complete:
 
Number of units: 1 family Duplex
 
Type foundation: Basement
Slab
Crawlspace over slab
Other (list in remarks)
(If basement, what % is finished?)
% FINISHED
 
Type Construction: Frame
Brick/Veneer
Stone
Other (list in remarks)
 
Type Roof: Shingle
Wood Shake
Tar/Gravel
Spanish Tile
Metal Other
 
Number of stories: One 1.5
Two Three
 
Do you own animals or pets? Yes No
If yes, list type/for dogs, list breed:
 
Are You a Smoker or Non-Smoker? Non-Smoker Smoker
 
Do you have a smoke detector, carbon monoxide, deadbolt, security system, visible to neighbors? (list security features in remarks) Yes No
 
# of feet to nearest
fire hydrant:
# of miles to nearest
fire station:
 
Does Home Have a Garage? Yes No
Tell whether built in, detached/attached, and how many cars?
 
Does Home Have a Pool? No Yes
If yes, tell whether it is above ground or in-ground, if it is fenced, and wether or not you have a diving board
 
Do you own a trampoline? No Yes
 
Do you have a porch or Deck? Yes No
If yes, how many square feet?
 
Any business equipment stored on premises? No Yes
 
Do You Want Flood or Earthquake Insurance? Yes No
 
Year Home Purchased:
 
Currently Insured? Yes No
 
Current Carrier & Expiration Date?
Current Premium (Optional) - this helps
us find extra discounts for you!
$
 
Prior Claims in last 8 years? Yes No
Describe claims in detail, and amounts paid out:
 
Rate Your Credit History and Past Insurance Payment History:
(Some companies products are
based on your credit and payment history.)
Excellent Fair
Poor Horrible
 
Plumbing type: Copper Galvanized
Mixed (Copper/Galvanized)
 
 
Heating Type: Gas (Propane or natural)
Electric
Oil
 
Is there a fuel tank in basment?
(If yes, list tank location in remarks)
No Yes
 
Circuit Breakers or fuses? Breakers Fuses

# Bedrooms: # Bathrooms:
 
# Fireplaces: # Chimneys:
 
If home is over 25 years old, what year(s) were the following updated? (1) Wiring, 2) Heating, 3) Plumbing, 4) Roof 3)
 
Any business on premises?
(If Yes, list in remarks)
No Yes
 
Special features
(i.e., deck, air conditioning, alarm systems, pool, etc.)
 
Coverages:
 
Dwelling Cov. $ Contents $
Liability Cov. $ Deductible $
($250, $500, $1,000, etc.)
 
Comments/Remarks
(describe any scheduled jewelry, in-home business, oil tank location, or other special coverages/remarks here):
 
Send my quotation via: E-Mail Fax
Regular Mail
Call Me By Phone

Thank you for filling out this form COMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

Yes, I Agree. Please Send Me a Quote NOW!


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Immanuel Insurance Agency | PO Box 300 | 3 Brittany Lane | Barrington, NH 03825
Phone: 603-335-4300 | Fax: 603-822-7101
Email: david@immanuelins.com | Office Map/Directions | About Us |
Privacy Notice | NH Insurance License #3356286

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