Colton, Downey & Associates, Inc.


	1122 Veterans Drive, Jacksonville, IL 62650 217-243-8484 FAX 217-243-3301 109 Morse, Roodhouse, IL 62082 217-589-5890 FAX 217-589-4925

Home, Auto, Boat, Mobilehome, Motorcycle, Rental Dwelling, and more.

As Business Grows, and You Start To Have Insurance Woes, Call The Pros

24 Hour Claim Services

Home Quote Form:


Home Information
Name:
E-mail Address:
Daytime Phone Number:
Evening Phone Number:
When to contact:	Daytime
	Evening
Street Address:
City:
State:
Zip:
Social Security Number*
*Your Social Security Number may be used to get an insurance score or claim information.
Do you currently have Homeowners Insurance?	Yes No
With what company?
Does anyone in the household smoke?	Yes No
Date of Birth:
What is the ZIP code, if different than listed above?:
Which of the following best describes your home?
Which of the following apply to your home?
Is Your Home: Inside City Limits?
Outside City Limits?
Is a Fire Station: Closer than 5 miles away?
Farther than 5 miles away?
How much coverage do you need on your house?
What is the approximate square footage of the house?
Approximately, in what year was your home built?
Loss History
How many homeowner's losses have you had in the last 6 years?
Please provide a brief description of any losses on your homeowner's:
Date:
Date:
Date:
That's all the information we need to give you a quote on your homeowner's insurance. If there is additional information you think would help us give you a more accurate quote, please put all the notes you want below. Also include any special items you would like to list on your policy, a certain coverage amount for your contents for unattatched structures, or special coverage you want included.


All quotes depend upon the losses on your homeowners and an insurance score. Upon receipt of the above information, our office will contact you on the next business work day. This site is to provide a quote and coverage cannot be bound on this site.


	Click here to find the NADA value of your vehicle.

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