P.O. Box 33341
Washington, DC. 20033
Tel: (202)296-8614
Toll-free 1-800-964-8614
Fax: (202)296-6333
E-mail: info@paulbalep.com
Homeowners/Condominium/Renters Insurance Quotes Request Form
<<Independence is number one>>. We are nonexclusive producers who represent an average of eight companies-not just one. PaulBalep can evaluate and compare the products of several fine companies to find you the right combination of coverage and value.
Homeowners Profile
To help our insurance representatives better understand your homeowners insurance needs, please provide the following information.

Privacy Notice: All information you provide is solely used for the purpose of providing you with quotes. We will never sell, give, or otherwise transfer your personal information to any person or entity other than the insurance companies, agents, and representatives selected. In some cases insurance companies we work with may request credit score.
Please enter the contact person's first and last name who will be responsible for processing the quotes:
Location of your residence Address:
Do you now reside, or plan on residing at this property within the next 12 months? yes no
Is business or farming conducted on this property? yes no
Do you have any of the following breeds of dogs: Chow, Doberman, German Shepherd, Pit Bull, Rottweiler, Wolf, Hybrid, or mix of these? yes no
Please select the property type:
A. Single Family Home B. Multi Family Home C. Apartment D. Duplex E. Condominium F. Townhouse G. Mobile Home H. Other
Do you currently own (or are you in the process of purchasing) this property? yes no
What is the basic construction?
A. Frame B. Masonry C. Masonry-Veneer D. Superior
Type of fire alarm?
A. Central Station B. Fire Department C. Local
Property Accessories (Check all that apply)
A. Central Burglar Alarm B. Central Fire Alarm C. Smoke Detectors D. Dead Bolts E. Covered Deck
F. Fireplace G. Trampoline H. Air Conditioning I. Swimming Pool J. Tennis Court K. Fire Extinguisher
L. Uncovered Deck
Select discounts that apply?
A. Fire sprinkler system B. 24-hour guard C. Gated community D. Secure building
Is one of the people named as an insured over age 58, retired and living in the household? yes no
Cost to rebuild your residence? yes no
What is the square footage of the residence? If over 5,000 sq. ft, please call for a quote.
Select the construction classification of the residence.
A. Average B. Luxury C. Custom
Number of stories
A. 1-story B. 1-5 story C. 2-story D. 2-5 story E. 3-story F. Bi-level G. Tri-level
Select the type of covering on the exterior walls:
A. Solid masonry B. Painted concrete block C. Solid brick D. Solid
Is there a basement?
A. No B. Fully Finished C. Partial Finished D. Unfinished
Number of bedrooms Number of bathrooms
Current residence status?
A. Own B. Rent C. Live with parents D. Dormitory
Claims Summary
Please declare any claims or losses you have reported to your insurance company within the past 5 years. If you don't have any claims to declare, you can skip this section and continue.

Requested Homeowners Policy Coverages
An example
Cost to rebuild value:
Coverage for other structures:
Coverage for contents:
Coverage for loss of use:
Personal liability coverage:
Medical Payments:
Select your deductible:
Helpful Hints
  • Do you have collectibles? Your standard coverage for contents may not be enough to protect any special collection antiques, artwork or even jewelry. Ask about inexpensive endorsements or riders you may need.
  • Save up to 15%. Most insurance companies offer a discount when you buy both your auto and homeowners insurance from them. The savings can be as much as 15%.
Please provide us with any additional information that may be helpful in providing you the most accurate quote:

Insurance Information
Please tell us more about your current or recent insurance policy. Be as accurate as possible.
Your most current insurance company? (You won't receive a quote from this company)
What date does your current policy expire/renew?
How long have you been insured with your current insurance company?
Years Months
Extremely important: How long have you been continuously insured?
Years Months
Contact Information
In most cases, the insurance companies we work with will send you your quotes via email. In some cases, when additional
information is needed, they will need to speak with you personally. Please provide valid contact information as requested below.
First Name: Last Name:
Street Address: Apt or Unit :
City: Country:
State: Zip Code:
Please enter a valid E-Mail address:
Business Telephone Number:
Contact Telephone Number: Ext:
Fax Number:
If necessary, best time of day to contact you? Anytime Morning Afternoon Evening
How quickly do you need your request processed? Day(s)
Please provide any comments you have for the agents who respond to this quote request:

Where permitted by law, some insurance companies may confirm your information, through the use of consumer
reports, which may include credit score and driving record.
By submitting this information, I request that insurance companies subscribing to the PaulBalep quote service contact me with quotes via email, telephone and fax using the information I have provided.