Robert Rood Insurance Agency - Rogue Valley Oregon

Home Insurance Quote Form

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Contact Information
First Name* Middle Intial	Last Name*
Address Unit #	City State
Zip Code	Home Phone
Work PhoneExt	Email*
Date of Birth*	Smoker*YesNo
Your Property Information
Street Address*Unit #	City*
StateZip Code*	Year BuiltYear Purchased
Home Value*	Home Type*
Number of StoriesSquare Feet of House	Construction*
Interior Walls	Garage TypeAttached*YesNo
Upgraded Kitchen*YesNo	Total Number of Full Bathrooms*
Total Number of Half Bathrooms*	Number of Upgraded Bathrooms*
Roof Type*	Roof AgeYears Warranted
Central Air Conditioning*YesNo	HeatingFireplaceYesNo
Home Options: Pool Spa
Security Options: Smoke Detector Deadbolt Fire Extinguisher Automatic Fire Sprinklers Local Burglar Alarm Monitored Alarm
List any replacements, upgrades or repairs done to home and dates completed
Homeowners Association Yes No
Have you reported a claim in the last three years? Please explain:
Questions
Desired coverage amount (cost to replace structure)	Desired deductible amount
If you have coverage now, who is your insurance co.?	If you have coverage now, when does it expire?
To receive a larger discount, would you consider also insuring your cars with Farmers? Yes No	If this is a new home, would you like a free home warranty quote also? Yes No
Would you like mortgage protection? Yes No	How should we contact you?
What time should we contact you?
Do you have any questions or suggestions?

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Cell: 541-261-2711 Business: 541-245-4056 Claims: 1-800-435-7764 Email: rrood@farmersagent.com