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Independent Insurance Agency
 
Homeowners Quote Request Form
  
 


Call (860) 354-3921 and an agent will help process your quote request.

We will need the information on the form below in order to process your quote request.
Print out this page, fill in the information, and keep it for reference when you speak with us.
Or, fill out the page and fax it to us at (860) 350-9591. An agent will call you.
Please do not e-mail personal information.

  
 
First Name: Mid. Init.: Last Name:
Street Address:    
City: State: Zipcode:
Home Phone:   Cell Phone:
e-mail:    
SSN#    
Date of Birth:    
     
Previous Insurance Company:    
Dwelling Limit:    
Liability Limit:    
Deductible:    
Year of construction:   Type of construction:
Number of families:    
Dwelling usage:    
Heat type:    
Updates:    
Roof year:    
Plumbing:    
Heating:    
Electrical:    
Pets:   Dog Breed(s):
Any losses in last 3 years:    
When may we call you:    
 
 
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New Milford Insurance Agency
30 Bridge St., Suite 101, PO Box 449
New Milford, CT 06776
Phone: (860) 354-3921 Fax: (860) 350-9591
sales@nm-ins.com