Homeowners Quote - RSI Insurance Agency, Inc.

All RSI Bank offices will be closed on Monday, July 4th in observance of Independence Day.
Locations & Hours

Personal Information
Full Name:
Date of Birth:
Address 1:
Address 2:
City:
State:
Zip:
Primary Phone Number:
Secondary Phone Number:
Email Address:
Employer:
Occupation:
Years at Current Job:
Insurance Information
Estimated cost to replace your home:	(Coverage 'A' on your current policy; NOT market value)
Is your home currently insured?:	Insured YesNo
If yes: Name of Carrier:
Years Insured:
Current or Desired Deductible:	Insured $250 $500 $1000
Do you have any prior claims?:	Insured YesNo
If yes, please explain:
Has coverage been declined, cancelled, or not-renewed in the past 3 years?:	Insured YesNo
If yes, please explain:
Home Information
Primary residence?:	Primary Residence YesNo If not, what is your primary address?
Address 1:
Address 2:
City:
State:
Zip:
How many years have you lived at your primary address?:	If less than 3 years, what is your previous address?
Address 1:
Address 2:
City:
State:
Zip:
Have you had any Bankruptcies or Foreclosures?:	Insured YesNo
If yes, please explain:
Is the home to be insured a condominium? :	Insured YesNo
Square Footage:
Year Constructed:
Number of Bedrooms:
Number of Bathrooms:
How Many Floors?:	Insured 1 Story 1.5 Story 2 Story Bi-Level Tri-Level Other
Other:
Fireplaces:
Attached Garage:	Number of cars
Detached Garage:	Number of cars
Type of Foundation:	Insured Slab Crawlspace Over Slab Basement Other
Other:
Type of Exterior:	Insured Wood Stucco Masonry Brick Veneer Aluminum Siding Vinyl Siding Other
Other:
Type of Roof:	Insured Shingle Wood Shake Tar/Gravel Spanish Tile Metal Other
Other:
Age of Roof:
Type of Plumbing:	Insured Copper Galvanized PVC Mixed Other
Other:
Type of Heat:	Insured Gas Oil Electric Other
Other:
Tank Location:	Insured In-Ground Above Ground
Electric Panel:	Insured Circuit Breakers Fuses
Other Features (Check ALL that apply):	Insured Dead Bolts Smoke Detectors Fire Extinguishers Central Station Fire Alarm Central Station Burglar Alarm Central Air Home Located within 5 Miles of Fire Station Home Located within 1000 Feet of a Fire Hydrant Deck Swimming Pool Above Ground Swimming Pool In-Ground Swimming Pool Diving Board Swimming Pool Slide Trampoline Home Located within City Limits
Plumbing:	Year of latest improvements
Plumbing Improvement Type:	Insured PartialFull
Heating:	Year of latest improvements
Heating Improvement Type:	Insured PartialFull
Electric:	Year of latest improvements
Electric Improvement Type:	Insured PartialFull
Are there any smokers in the home?:	Insured YesNo
Do you own animals or pets?:	Insured YesNo
If yes, list type(s)/For dogs, list breed:

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