Office  Hours: M-F  9am to 5pm
670 E 32nd St. Suite 12
  Yuma, AZ   85365    
Call today: (928) 317 1212

Home Quoting Information on Traditional Site Built Homes

Home Quote Application


Please provide as much information as possible within the application below for the most accurate quotes available.
Upon completion of this information, hit "submit" once and the form will be sent to a representative for quoting. The information provided will be quoted among the multiple insurance carriers our office proudly represents. A representative will respond with the quotes via the contact option selected, normally in 1 business day or less.

Thank you for your time and we look forward to assisting you!

Applicant Information
First Name:
Last Name:
Address Street 1:
Address Street 2:
City:
Zip Code: (5 digits)
State:
Mailing address:
Marital Status: Single
  Married
Date of Birth:
Social Security #:  (Optional)
Co-Applicant Information
First Name:
Last Name:
Relation to Insured:
Date of Birth:
Is the Co-applicant a co-signer/co-owner 
of home?     
Yes
  No
Contact Information
Daytime/Home
Phone #:
Cell Phone #:
Work Phone #:
E-mail:
Preferred method of contact:  Daytime/Home
  Cell Phone
  Work
  E-mail
Person of Contact:
Is the person of contact a:  Realtor
  Bank/Loan Officer
  Other (explain below)
If the person on contact is a Realtor or Bank/Loan Officer, please enter their phone # and the name of the office they represent:
Financial Information
Home Ownership status:
*Lienholder/Bank Name:
*Lienholder/Bank Address:
*Lienholder/Bank City:
*Lienholder/Bank State:
*Zip Code:
Loan # for reference with lienholder:  (Optional)
If the home is not a new purchase, how long have you owned the home?:
Requested effective date:
Property Information
Property Type:
Occupancy:
Purchase Price: (USD)
Appraised Value:  (Optional)
*Requested amount of homeowners insurance on policy: (Replacement Cost)
Does the amount of the requested homeowner insurance include the value of the land? No
  *Yes
*If yes, please indicate the amount of the home only:
 (USD)
Year of home?:
What is the square footage of home? (Livable space only):
Please describe the type of foundation:  Slab
  Crawlspace
  Basement
  Other (explain below)
Other type of foundation:
What type of siding materials?:  Hardboard/Hardi-board
  Stucco
  Brick
  Other (explain below)
Other type of siding materials:
What type of roofing materials?:  Shingles (Asphalt/Comp)
  Tile (Clay)
  Rolled roof (tar and gravel)
  Other (explain below)
Other type of roofing materials:
What type of heating source?:  Heat pump
  Forced Air
  Electric- baseboard
  Furnace- gas or electric
  Other (explain below)
Other type of heating source:
Is there a permanent swimming pool on premises? No
  *Yes
*If yes, is the pool completely fenced with a self-locking gate?  No
  Yes
During the time you have owned the home, have there been any losses and/or claims on the home in the past 5 years?  No
  *Yes
*If yes, please give information on what type of loss/claim, such as wind or water, and apx. when the loss occurred and how much was paid out on the claim:
Is there a fireplace in the home?  No
  *Yes
*If yes, how many?:
Other Information
Has this home had insurance coverage, in your name, for the past 12 full months?  No
  *Yes
*If yes, with what company?:
Do you have any other structures on the property, such as a shed?  No
  *Yes
*Please describe type of structure and size:
Do you have a garage or carport?  No
  *Yes
Is the garage or carport attached or unattached from the  main house?  Attached
  Unattached
How many cars park in the garage or carport?:
What is the primary insureds occupation?(Ex. Retired, Doctor, Sales Associate):
Do you have any dogs on the property?  No
  *Yes
*What type/breed of dog and how many?
Comments:
I authorize the Sheltra Insurance Group to verify
my credit and/or insurance history.