Homeowners Quote Form

Please fill out the following form for a Homeowners insurance quotation in the state of Kentucky. After clicking the submit button, the form will be sent to Simms & Montgomery and an agent will contact you to review a personalized quotation. Please note that Simms & Montgomery is authorized only to write insurance in the state Kentucky.

If you have any questions about this form or about coverage in general, please contact us.

In order to provide you with the most accurate quote available, please include your Social Security Number. However, if you would rather not enter that information, we can still provide you with a quote.

Personal Information

Name (first, middle, last) :

Address Line 1:

Address Line 2:

City, State Zip

E-mail:

Home Phone (000) 000-0000 :

Work Phone (000) 000-0000 :

Fax (000) 000-0000 :

Social Security # (required):

Best time to call:

Residence Information

Type of policy (homeowners, condo, renters):

Effective date of coverage (00/00/0000) :

Location of residence (if different from above):

City, State Zip

Is this a Primary or Secondary residence:

Approximate year of construction (0000) :

Construction type:

Any losses in the last 3 years:

Number of families at residence:

Coverage Information

Value of home, or amount of current insurance:

Personal property amount
(condo and renters only):

Personal Liability (each occurrence):

Deductible:

Endorsements:

Replacement cost options
(check all that apply):

Dwelling: Contents:

Protective devices
(check all that apply):

Smoke detectors:		Dead bolt locks:
Fire extinguisher:		Non-smoker:
Central Station Burglar Alarm:		Central Station Fire Alarm:
Police Station Direct Alarm:		Fire Station Direct Alarm:
Automatic Sprinklers:

Optional Coverages:

Earthquake Coverage:

Scheduled Property (enter an amount for all that apply):

Jewelry:	vaulted?	Fine Arts:
Golf Equipment:		Silverware:
Cameras:		Furs:
Musical Instruments:		Guns:

Comments or additional pertinent information:

Submitting an insurance quotation request to Simms & Montgomery does not constitute a binding confirmation of new or altered insurance coverage. Verbal or written confirmation must be obtained from Simms & Montgomery to confirm binding or altering coverage.