Insurance Agent:
Marvin C. Sterling

Do you have questions about filling out this form?
Contact Farmers Agent at farmersagent@arvisom.com

HOMEOWNERS INSURANCE: Online Quote Form


HOMEOWNER'S NAME: HOMEOWNER'S ADDRESS:
CITY & STATE: ZIP CODE:
HOME PHONE: WORK PHONE:
E-MAIL ADDRESS:
NAME of CO-OWNER/SPOUSE (if any):

As part of our underwriting process for all applicants, to provide you with an accurate premium amount, we must ask you a series of questions. Your answers to some of these questions will be confirmed through consumer reports, which may include credit information. This information will be available to all of the business entities that make up the Farmers Insurance Group of Companies. Do you wish to continue?
(Please indicate "YES" or "NO"):

Is owner a smoker? (YES/NO):
Is co-owner a smoker? (YES/NO):

A. Birthdates and Social Security Numbers of Owners:

1. NAME: Date of Birth:
    Social Security Number:
2. NAME: Date of Birth:
    Social Security Number:
Year dwelling was built:
Square Footage of Dwelling:

AGE OF ROOF:

ROOF TYPE (e.g., Asphalt/Shingle, Asphalt/Fiberglass-Hail Warranted, Asphalt/Fiberglass-300 lb, Slate, Concrete/Cement-Fiber Tile-6, Copper, Rock/Tar Gravel, Rolled Asphalt-Flat, Rolled Asphalt-Peaked, Sheel Metal Panel, Asphalt/Fiberglass or Dimensionless Asphalt, Spanish Tile, Steel Tile/Shingle, Synthetic Shingle/Tile, Wood Shingle/Shake):


POLICY TYPE (e.g., Homeowners, Condo/Townhome, Landlord Protector, Renters, Mobilehome-in-Park, Mobilehome-not-in-Park):


NUMBER OF UNITS: OUTSIDE OF CTY LIMITS? (Y/N):

TYPE of SIDING ON DWELLING (e.g., Adobe, Alum/Plaster/Vinyl over Frame, Asbestos Siding, Comp Roll Siding, Frame-with-0%-to-33%-Masonry-Veneer[BRICK], Frame-with-34%-to-66%-Masonry-Veneer[BRICK], Frame-with-67%-to-100%-Masonry-Veneer [BRICK], Log Home, Log-Home-with-Finished-Interior, Solid Masonry-Brick/Stone/Etc):


PROTECTIVE DEVICES:
Deadbolts on Exterior Doors? Smoke Detectors?:
Fire Extinguishers? Year Renovated?:
Central Alarm (monitored)? Local Burglar A. (sounds locally)?:
Sprinkler? Age of Heating?:
Age of Plumbing? Electric?:

STYLE CODE (e.g., Bi-Level/SRD Ranch, Geodesic Dome, Modular Home, Split Level, Townhome [Center Unit], Townhome [End Unit], Underground Dwelling, 1 Story, 1 1/2 Stories, 2 Stories):


GARAGE TYPE (e.g., Carport, Detached, 1-Car Attached, 1-Car Built-In, 2-Car Attached, 2-Car Built-In, 3-Car Attached, 3-Car Built-In, None):



Nearly finished! (Please continue on PAGE 2.)

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D. Tickets/Accidents in Past 3 Years:

1. DRIVER'S NAME:
Ticket Dates: Dates of Major Citations (past 5 yrs):
Dates of At-Fault Accidents:
Dates of Not-At-Fault Accidents:
2. DRIVER'S NAME:
Ticket Dates: Dates of Major Citations (past 5 yrs):
Dates of At-Fault Accidents:
Dates of Not-At-Fault Accidents:
3. DRIVER'S NAME:
Ticket Dates: Dates of Major Citations (past 5 yrs):
Dates of At-Fault Accidents:
Dates of Not-At-Fault Accidents:
4. DRIVER'S NAME:
Ticket Dates: Dates of Major Citations (past 5 yrs):
Dates of At-Fault Accidents:
Dates of Not-At-Fault Accidents:

E. Desired Insurance Coverage:

VEHICLE #1 Liability Limits:
Uninsured Motorist Limit:
Medical:
Comprehensive Deductible:
Collision Deductible:
VEHICLE #2 Liability Limits:
Uninsured Motorist Limit:
Medical:
Comprehensive Deductible:
Collision Deductible:
VEHICLE #3 Liability Limits:
Uninsured Motorist Limit:
Medical:
Comprehensive Deductible:
Collision Deductible:
VEHICLE #4 Liability Limits:
Uninsured Motorist Limit:
Medical:
Comprehensive Deductible:
Collision Deductible:

F. Additional Questions:

Any stereo equipment in car other than factory-installed? If yes, is its value?

Any campers or trailers? If yes, is the value?

Has any member of household ever had their license cancelled, suspended, or revoked?
Driver: Date:

Current Insurance Company (if any):
Has any company ever canceled or declined to renew your insurance coverage?
If yes, company name and date:

You may include any additional information here. Please feel free to include your comments.

FARMERS INSURANCE GROUP


AGENT: Marvin C. Sterling
farmersagent@arvisom.com
2200 Shadowlake Drive
Oklahoma City, OK 73189-2165