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Homeowners Quote

Please complete the following Homeowners Quote form and click Submit. A Wickersham Insurance Agent will contact you with your quote information once we have processed your request.

Contact Information
First Name *
 Last Name *
Street Address
City
 State
 		Zip Code
E-mail Address
Contact Phone *
 Best Time to Call
AM    PM   
Occupation
 How Long at Current Job
 

Home Information
How Long at Present Address
 Year Home Was Built
 Type of Dwelling
Square Footage
(excluding garage & basement)
 # of Claims in Last 3 Years
 Occupancy
Fire Protection
Information:		 # of Feet from Hydrant
 # of Miles from Nearest Fire Dept.

 Structure Information

Type
 		Construction
 		Roof
 		Age of Roof (in years)
Foundation
 		Garage Type
 		# Cars in Garage

 Home Features

# Full Baths
 # Half Baths
 # Bedrooms
 Basement
 		Basement Sq Ft
Deck Sq Ft
 Porch Sq Ft
 Patio Sq Ft
Fireplaces: # of Chimneys
 # of Hearths
 # of Woodstoves
Other: Pool
 		Fenced Pool
 		Trampoline
 		Dogs
 		Breed(s)

 Additional Features

Heating System
 		Central Air
Yes   
Central Vac
Yes   
Security Alarm
 		Fire Alarm
 		Smoke Detector
Yes   

 Liability Limit / Deductible / Coverages

Liability
 		Deductible
 		Replacement Cost
Contents
 		Replacement Cost
Dwelling
 

Comments / Questions

Please include any comments or questions you feel appropriate for this quote. If you have additional information that could not be included above (other features, etc.), please feel free to enter that here.

* Required to submit this form



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Wickersham Insurance Agencies

758-7999

788-1800

2160 Hwy. 95 Suite #2
Bullhead City, AZ 86442

8550 Hwy. 95
Mohave Valley, AZ 86440

Colorado River Insurance Center

855-2742

2005 McCulloch Blvd.
Lake Havasu City, AZ 86403

EMAIL: wickersham@frontiernet.net








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