Borg & Borg Insurance

Home Quote

Fill out a short form and recieve a prompt response from one of our superior staff members.

Personal Information

Name:
Address:
City:
State:	Zip code:
Phone (hm):	please include area code
Phone (wk):	please include area code
Fax:	please include area code
e-mail

Coverage

Replacement Cost on Building?:	yes no
Replacement Cost on Contents?	yes no

Dwelling Limit:
Contents Limit:
Liability Limit:
Medical Limit:

Property Information

Address (if different from above):
City:
State:
Zip Code:

Is the property within 1000 feet of water?

yes no

Age of Dwelling:

years

Square Footage (approx.):
House	sq.ft.	Basement	sq.ft.
Garage	sq.ft.	Deck	sq.ft.

Please check off the applicable boxes:

Living Room		Family Room		Utility Room		Fireplace
Kitchen		# Bedrooms		Basement		Central A/C
Dining Room		# Full Baths		Attic		Porch
Den/Study		# Half Baths		Foyer		Deck

Scheduled Items:

	Total Value ($)
Jewelry
Furs
Fine Arts
Cameras

Please leave a note if you have any other concerns.

How would you like your quote sent?