Wheeler Agency, Inc. 
(651) 766-7867 
or toll free: 1-888-765-2554
 

Homeowner Quote

This is a quote request form. Submitting this form does not represent coverage or binding of coverages of any kind. By submitting this form, you agree to the above statement.

Location Information

Name (First & Last)
Spouse's Name
Address
City
County
State
Zip Code
Home Phone
Work Phone
Cell Phone
Email Address

Basic Limits

Dwelling Limit $
Other Structures $
Personal Property $
Loss of Use $
Personal Liability $
Med Payments $
Deductible $

Additional Information

Company Now With
Expiration Date
Insured Date Of Birth
Social Security Number (Optional)
Spouse Date Of Birth
Social Security Number (Optional)
Home is 1-family 2-family other
Construction Frame Brick other
Within City Limits Yes No
Hydrants within 1000 feet? Yes No
Year Built
Year Roof Replaced
Year Wiring Updated
Total Amps
Circuit Breakers Yes No
Year Plumbing Updated
Year Heating Updated

Scheduled Personal Property

Jewelry $ Cameras $
Silverware $ Guns $
Musical Instruments $ Furs $
Golf Equipment $ Fine Arts $
With Breakage Yes No

Protective Systems

Central Burglary Alarm Yes No Cental Fire Alarm Yes No

Additional Liability

Number of Additional Residences
Owner-Occupied
Location:
Rented to Others
Location

Watercraft

Boat Type Motor Type O/B I/B I/O
Length Horsepower
Total insured for boat, motor, trailer $ Maximum Speed

Additional Information

Do you have a woodburning stove Yes No
Do you have a swimming pool Yes No
Fenced Yes No
Do you have a trampoline Yes No
If you have any pets list breed
Is there any business conducted on premises Yes No

Going back five years, have you had any claims on your homeowner policy?

     Yes   No           Describe:
If you have any snowmobiles or ATVs, describe in comments below
comments:
Name of Your Group
Credit Union
Bank
Association
Other
A report will be ordered on your credit history from a consumer reporting agency for use in determining an insurance score. This insurance score will be used to underwrite and/or rate your insurance policy. The better the score, the lower your insurance premium. The inquiry will not affect your credit history in any way. We are committed to respecting your privacy and safeguarding your personal information. Please acknowledge that you have read and understand this message. Yes