How did you find our site? __________________________
The following must be filled in to receive an accurate quote:
Policy Renewal Date: __________
Present Insurance Company: ______________________________
Date Submitted: _____________
Name: _______________________
Address:__________________________________________________
City:__________________________
Zip Code:_____________
County: _________________
Home Phone: ___________________
Work Phone: ___________________Occupation: ____________________
Employer: ____________________
Number of years at present employment: ____Have you had any financial problems in the last 5 years. ______
If so, describe: ___________________________________________________________
__________________________________________________________________________Have you had any losses in the past 3 years? If so, list date, description and amount paid.
______________________________________________________________________
______________________________________________________________________Year home built._________ Brick ___ Frame ___ Other _________________
Date of any improvements: Electrical ______ Heating _____
Plumbing ______ Roof _________Amount of insurance that it would take to replace your home today $__________
Amount of insurance presently on your home $____________ Contents $__________Please fax this form to us at 804-261-7945
Or mail to:
Ford and Thomas Insurance Agency, Inc.
6809 Stoneman Road
PO Box 9640
Richmond VA 23228To be used for the State of Virginia only.