Customer Quote Request Form

We would like to thank you for choosing Vargas & Vargas Insurance Agency Inc.!

We realize that as a consumer you have many choices when it comes to insurance agencies. Please know we appreciate your business and look forward to assisting you with all of your insurance needs.

Your complete satisfaction in our customer service is our goal.

Please take a few moments to complete this "Customer Quote Request Form" to assist us in better serving you.
Please provide some general information
What is the zip code of the home you are insuring?
Is this home a new purchase? Yes No
Are you currently insured, or have you been insured in the last 30 days? Yes No
Now tell us about your current insurance information
What is your current insurance company?
How long have you been with this company?
How much is your current premium?
When does your policy expire?
Now tell us a little about your home
What type of Home are you insuring?
What is the occupancy status of this home?
Address to be insured
City
State
Zip Code
County
What year was the home built?
What type of dogs do you have, if any?
What is the total square footage of the home?
How many stories (excluding basement) are there?
How many bedrooms do you have?
How many bathrooms do you have?
Type of Electical System
Approx age of furnace (in years)?
Approx age of roof (in years)?
Now tell us a little about your home features
What type of heat source do you use?
How many fireplaces do you have?
How many wood stoves do you have?
What type of garage do you have?
How many wooded porches, patios, or decks do you have?
How is your dwelling sided?
What type of roofing do you have?
Describe your foundation or basement
How far away from a fire station is your home?
How far away from a fire hydrant is your home?
Please check any of the following features that you have at your dwelling
Burglar Alarm Dead Bolts
Fire Alarm Fire Extinguishers
Manned Security Station Monitored Burglar Alarm
Smoke Detectors Tennis Courts
Central Heating/Air Cathedral/Vaulted Ceilings
Hardwood Floors Enclosed Porch/Patio
Unfenced Pool Fenced-In Pool
Hot Tub Indoor Sprinklers
Now tell us how much coverage you need and if you have any claims in the past
How much coverage is needed on the dwelling? (in dollars; for example 250,000)
How much coverage is needed on the contents?
(If you do not want contents coverage, enter 0)
Requested amount of liability
Requested Deductible
Many companies use credit information for rates and discounts.  How would you honestly rate your credit history?
How many homeowners claims have you filed in the last 5 years?
Personal Information
Please let the agents you are matched with know how they can get in touch with you. Your contact information is given only to the agents you are matched with. We will never sell, give, or otherwise transfer your personal information to any person or entity other than these agents.
First Name
Last Name
Gender Male           Female
Check here if your contact address is the same as your property address.
Address
Apartment / Suite
City
State
Zip Code
* Best Phone
Alternate Phone
Email
Verify Email
How did you hear about Vargas & Vargas?
Best Time to Contact You Morning Afternoon Evening
Best Method to Contact You Phone Email US Postal


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