11/20/2008 08:14:48 AM

138 River Road
Suite 306
Andover, MA 01810
Tel: 978-682-9633
Fax: 978-681-0623
Toll Free: 1-888-430-6200


Automobile Insurance
Whether for business or personal use we have the most competitive auto insurance programs around.
Business Insurance
We offer commercial insurance programs for businesses of all sizes.
Home and Life Insurance Home, Life, Watercraft, Renters, Insurance and more.....

Home | About Us | Products | Services | Staff | Contact Us | Carriers
Homeowners Insurance Quote Request
Request Quote for Homeowners Insurance

HOMEOWNER QUOTE

No coverage is bound until you are contacted by one of our representatives

 CONTACT INFORMATION
 Name  
 Street Address  
 Street Address  
 City, State, Zip  
 Phone Number   Home    Work 
HOME LOCATION
 Street Address  
 Street Address  
 City, State, Zip  
RATING INFORMATION
 1. What year was this home built?
 2. What type of construction was used?
 3. What style is your home?
 4. How will your home be used?
 5. How many rooms in your home?
 6. How many full bathrooms in your home?
 7. How many 3/4 bathrooms in your home?
 8. How many 1/2 bathrooms in your home?
 9. How many square feet on the first floor?
10. What type of home do you have?
 11. How many total square feet in your home?
 12. Do you have a fireplace?
      If yes, please describe what type
 13. Do you have a woodstove?
      If yes, please describe type and use
 14. Do you have a garage?
      If yes, please describe what type
 15. What is your primary source of heat?
 16. What is your secondary source of heat?
 17. Do you have a security system?
      If yes, please describe what type
 18. Have you had any losses in the past 3 years?
      If yes, please describe
 19. Is this your first home?
      If no, do you have current insurance?
 20. Do you own any pets?
    If yes, Please describe 
COVERAGE INFORMATION
 1. Do you want earthquake coverage?
 2. Do you have collections worth over $500?
    If yes, Please describe 
 3. Do you have any single piece of jewelry valued over $500?     
    If yes, Please describe 
 4. Do you have work tools that need coverage?
    If yes, Please describe 
 5. Do you operate a business out of your home?
    If yes, Please describe 

By completing and submitting this form you agree that no coverage is bound and no policy is in effect until you are contacted by one of our representatives.  All information submitted is held in the strictest confidence and is only gathered for the purposes of providing you an insurance quote. To provide the most accurate quote possible please complete all areas that apply.

UltraVision Agency Portal v.1.5
Copyright 2004, UltraVision Technologies, Inc. All Rights Reserved
Contact
For information please contact:


Customer Service
Request Auto Policy Change
Request Auto ID Card
Report Auto Loss
Request Certificate of Insurance
Report Property Loss
Get Directions to Barry & Campagna Agency
Privacy Statement
Request a Quote
Mass Auto Insurance Quote
Watercraft Insurance Quote
Business / Contractors Insurance Quote
Homeowners Insurance Quote
Life / Health Insurance Quote
Renters Insurance Quote
Motorcycle Insurance Quote