JOHNSON & BRYAN - Insurance Brokerage and Risk Management

Homeowner Insurance Quotation Request
Georgia Residents Only

For the fastest and most accurate quote, please provide as much information as
possible in the form below. This information will be kept confidential and will be used for
quote purposes ONLY!

Note: BOLD indicates required field

Name:
Address:
City:	State: Zip:
County:	(not country)
Day Phone:	Fax:
E-mail:
Date of Birth:	(mm/dd/yy)
Occupation:	How long at current job?

Current Policy Information

Current Homeowner Carrier:
Policy Expiration Date:
Premium Amount:	$ Every:

Underwriting Information

Year Built:
Type of Construction:
Deductible Amount:
Inside City Limits:	Yes No
Distance to Fire Hydrant:	feet
Distance to Nearest Fire Department:	miles
Replacement Cost Amount:	$
Is this your Primary or Secondary Home?
Personal Liability Limit:
Medical Payment Limit:
Owner Occupied:	Yes No
Square Footage:	sq. ft.
Number of Stories:

Protective Device Credits

Monitored Burglar Alarm:
Monitored Fire Alarm:
Automatic Sprinkler in All Living Areas:
Dead Bolts:
Fire Extinguisher:
Smoke Detectors:
Smokers in Household:
Homeowner Association:

Please list all claims reported and amounts paid in the last three years:

Additional Coverages (if needed)

Enter dollar amounts of itemized coverage for personal valuables.

Jewelry:	$
Jewelry in Bank Vault:	$
Silverware:	$
Fine Arts:	$
Furs:	$
Guns:	$
Camera:	$
Sporting Equipment:	$

Policy Will Not Automatically Include the following - Is Coverage Needed?
Earthquake Coverage Needed:
Flood Coverage Needed: