Get A Home Quote - The Roots Insurance

Named Insured

First Name *

Last Name *

Date of Birth

Gender

Male

Female

Employment

Occupation

Highest Level of Education

Contact Information

Phone *

Email *

Home Address

Home Address *

Home Address

City

State/Province

Zip/Postal

How long have you lived at this address?

Prior Home Address

Prior City

Prior State

Prior Zip

Is there any other person listed on the home besides you (and spouse/partner, if applicable)

Additional Insured Name

Additional Insured Relationship to You

Additional Insured Date of Birth

Purchase date of home

Is the home currently insured?

Current Carrier

Current Annual Premium

Length of Time with Current Carrier

Current Dwelling Coverage (Coverage A)

Closing Date

Purchase Price

Any home claims in the last 5 years?

Details

Deductible

Amount you would be responsible to pay in the event of a claim

Type of Dwelling

Style of Home

Notes - Style of Home

Year Built

Square Footage (excluding basement)

Age of Roof

Foundation

Type of Basement

Is the basement finished?

Percentage of basement finished

Exterior Walls

Notes - Exterior Walls

List details of each type of exterior wall covering (i.e. 20% vinyl siding, 80% brick)

Garage

Notes - Garage

Decks, Patios, Porches

Notes - Decks, Patios, Porches

Detached Items

Notes- Detached Items

Number of Bathrooms

Quality of Bathrooms

Quality of Kitchen

Type of Heating System

Age of Heating System

Do you have any fireplaces?

How many fireplaces?

Type of Fireplace

Any woodburning stoves?

Air Conditioning

Any animals in the home?

Details of animals in the home (type, breed, bite history)

Business operating in the home?

Details of business operating in home

Any jewelry, guns, furs or other collectibles that need to be insured?

Details of items (appraised value and brief description)

Would you like water back up coverage?

Limit:

Notes - Water Back Up Coverage

Any smokers in the home?

Do you have an alarm on the home?

What kind of alarm?

Local or Monitored?

Home Insurance Payment Plan

File Upload

Maximum file size: 134.22MB

If you have access to your current declarations page, please upload (we also like to see photos of the home, appraisals and any other documents to help us properly insure your home!)

Signature

I warrant the above to be true and understand the insurance contract will be considered based on my warranty.

Electronic Signature

Clear