Home Insurance Insured Information First Name Last Name Address City State Zip Phone e-mail Address Currently Insured: Yes Previous Claims Date Amount Description Date Amount Description Date Amount Description Additional Claims (enter a date, amount and description for any additional claims) Property Information Home Type Stick Built Mobile Home Manufactured Home Do you own or rent? Own Rent Home occupied by? Owner Tenant Brick or frame structure? Brick Frame Year Built Type of heating: Central(Thermostatically Controlled) Non-Central Heating method: Gas Electric Wood Other Lot Size / Acreage Insured Property Address Address City State Zip Coverage Information Cov A (Dwelling): Cov B (Other Structures): Cov C (Personal Property): Cov D (Liability): Deductible: $500 $1000 $1500 Additional Comments: Security Image Please enter the characters you see into the text box below. Agreement: Please check here if you agree to the following: I have read and agree to Whalen & Company's Privacy Policy and I understand that an agent will contact me regarding my quote. I also understand that this in no way binds coverage.
