Platte Valley Insurance Agency

Homeowners

308-856-4913

Below is the form we provide for an automobile insurance quote. We appreciate the time it takes to fill in the information. If you would rather not take the time required to do this online, but desire an agent to contact you, click here.

Thanks for your interest in a homeowners insurance quote from Platte Valley Insurance Agency. To receive an insurance quote, fill out form below. Please notice fields marked with '*' are required to be filled in prior to submission. Any questions or further information can be typed into the comments box. We respect your privacy and will use the information for only the purpose you sent it. We thank you in advance for your interest and time. All inquiries will be considered and responded to.

REQUEST for a HOMEOWNERS INSURANCE QUOTE

Personal Information:

Your Full Name:

   *

Mailing Address:

   *

City, State Zip:

   *

Telephone Number:

   *
Fax Number: 

Email:

  

Date of Birth:
 (for discount purpose)

    *

Rate your credit:
Property Information:

Property Address:

   *

City, State Zip:

   *

Mortgage Balance:

   *

Home Market Value:

   *

Number of Families living in home:

   *

Dwelling Type:
(example: single family, duplex, etc.)

   *

Number of Bedrooms:

   *

Number of Bathrooms:

   *

Number of Fireplaces:

   *

How many porches/decks:

   *

Year Built:

   *

Date property was purchased:

   *

Construction type:

   *

Number of Stories:

  1-story  1 1/2-story  2-story
 1 1/2-story  3-story *

If property is more than 1-story, what is the ground floor square footage:

   *

Total square footage of property:

   *

Foundation Type:

 *

Garage Information:

 *

Roof Information:

 *

Has roof been updated?

  yes  no *

If yes, what year?

  

Is there a pool on property?

  yes  no *

If Yes, is the pool fenced in?

  yes  no  not applicable *

If there is a pool, is there a diving board?

  yes  no  not applicable *

If there is a pool, is there a slide?

  yes  no  not applicable *

Fire Protection Distance Information:

 *

Is there a smoke alarm in building?

  yes  no *

Is there a fire extinguisher?

  yes  no *

Are there deadbolts?

  yes  no *

Is the electrical updated?

  Yes, recent update  no *

Are there circuit breakers?

  yes  no *

Does the electric circuit box have copper wiring?

  yes  no *

Does building have central air?

  yes  no *

How old is the heating/air conditioning?

   *

Are heat and AC thermostatically controlled?

  yes  no *

Energy Source:

 *

What is the Heating System?

 *

What is the Cooling System?

 *

Has the plumbing been updated?

  yes  no *

Does the plumbing have copper tubing?

  yes  no *

Does the building have interior automatic fire sprinklers?

  yes  no *

Is there a theft alarm?

  yes  no *

Does the building have a fire alarm?

  yes  no *

What is the fire district?

   *

Do you own a trampoline?

  yes  no *

Are there dogs on property?

  yes  no *

If yes, list number and breed of dogs.

 *

Are there any other pets on property?

  yes  no *

If yes, number and description.

 *
Current Coverage Information:

What is your current insurance company?

 *

Expiration date of current policy?

   *

Were there any losses or claims on policy in last 5 years?

  yes  no *

If yes, list date, amount paid and description of loss or claim.
Desired Coverage Information:

Dwelling Amount:

 Coverage A   *

Other Structures Amount:

 Coverage B   *

Personal Property Amount:

 Coverage C   *

Loss of Use Amount:

 Coverage D   *

Premise Liability Amount:

 Coverage E  *

Policy Deductible Amount:

 *

Do you want building replacement cost coverage?

  yes  no *

Do you want contents replacement cost coverage?

  yes  no *
Comments or Questions for Platte Valley Insurance Agency?
  
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Platte Valley Insurance Agency

121 North Tyler
P.O. Box 625
Elm Creek, Nebraska 68836

308-856-4913
308-856-4490
308-233-4892

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