Online Home Insurance Quote/Binder Request
Quote Only
*Policy/Binder
*Select this option if
coverage is needed for
loan closing, social will
be required
* Required Field
(Our offer will be
sent to this
person's attention)
*Requestor's Name:
Return Fax #:
*Return Voice #:
(Point of contact if our
staff has any questions)
Return Email:
(Selling price of the dwelling,
market value, or loan amount)
*Amount of Insurance:
*Type of Insurance:
Owner-occupied
Owner-occupied w/ plumbing coverage
Tenant-occupied
Fire Only (no other coverage)
Renovation/Builder's Risk/Vacant
# months for Renovation/Vacancy:
--------------
Flood
*Primary Insured Name:
Social Sec #
*DOB:
(Discounts apply to
persons over 50)
(Only required if binder is
to be issued for closing)
Second Insured Name:
Social Sec #
DOB:
--------------------------------------------------------
Insured Phone #:
1st-time home buyer
(Discounts apply to 1st-time home
buyers  and applicants with no history
of home insurance claims in last 5 years)
Prior Insurance claims
*Property Address:
Mailing Address:
(If different from
property address.)
*Construction:
Solid Masonry/Stone/Brick
(Please choose
predominant
type if more than
one option
applies.)
Brick and Frame/Siding combination
Wood frame or Siding (vinyl/metal)
Stucco
Hardi-plank
Size:
(sq ft)
Year built:
# Stories:
1     2     3
Vehicle
Storage:
Swimming Pool
Fireplace
Garage
Carport
None
Lender Information (optional)

Mortgagee Clause:
Loan #:
Closing Date:
Additional Notes:
This site is under construction, check back for updates as we move more of our
services to an online format.   
Copyright 2006, American Standard Insurance
Agency.


AMERICAN STANDARD Insurance Agency

                                                                                     Quote Request
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