Home Insurance Peoria Illinois Quote Form Ledbetter Insurance Homeowners Quote Form We would love to hear from you! Please fill out this form and we will get in touch with you shortly. 1 Personal Information2 Property Information3 Current Coverage Information Insured Last Name:Insured Full Name:Insured Middle Name:Return Call Phone NumberEmail* Date of Birth (For discount purposes):* Date Format: YYYY slash MM slash DD How would you rate your credit?ExcellentAbove AverageAveragePoor Property Address Street:City:State:IllinoisIndianaIowaMissouriOhioWisconsinZip Code:Current Worth of Home:Number of Families?What is the dwelling type?About what year was it built?What year was the property purchased?Is this a new purchase? Yes No Close Date MM DD YYYY What is the construction type?BrickFrameBrick VeneerOtherHow many stories?11.522.53Do you need coverage for a garage? Yes No Is(Are) your garage(s) attached or detached?*AttachedDetachedBothIf detached, how much would you like to insure it for?*If detached, frame or masonry*FrameMasonryAmount:What is the condition of the garage?ExcellentVery GoodGoodFairPoorComments:Does the building have a pool?YesNoIs the electrical updated?Yes, recently updatedNoAre there circuit breakers?YesNoIs the heating/ air conditioning thermostatically controlled?YesNoDo you have a trampoline?YesNoNumber of acres dwelling is located on:Are there dogs on the property?YesNoIf yes, how many and what is the breed of each dog?Are there any other pets or animals on the property?YesNoIf yes, how many and what is the description of each?Is your home inside the city limits?YesNoAre there handrails on all steps exceeding two steps?YesNoGeneral Condition of Home:ExcellentGoodFairPoorWho is paying the first year premium?InsuredMortgageeMode of payment:MonthlyQuarterlySemi-AnnualAnnualWhat is your current insurance company?What is the expiration date of current policy? Date Format: MM slash DD slash YYYY Dwelling Amount:Other Structures:Personal Property:Premise Liability:$100,000$300,000$500,000Policy Deductible:*$500$750$1000$2500$5000Do you want actual cash value policy or a policy to rebuild new?Cash Value PolicyPolicy to Rebuild NewDo you want contents replacement cost coverage?YesNoDo you want sewer and sump pump coverage?YesNoHave you insured this home in the last thirty days?*YesNoHow many months has the house been uninsured?*Additional InformationIs there a vacant dwelling next to your home?YesNoIf yes, explain at bottom of page.Where there any losses or claims in the last 5 years?YesNoIf yes, explain at bottom of page.Is your home currently in need of or under any repair or renovation?YesNoIf yes, explain at bottom of page.Questions or CommentsNOTICE: Some companies use an insurance score. This can often improve your rate. If you would like us to use this underwriting tool please provide us your social security number in the remarks box below. (Rules of the Fair Reporting Credit Act and Federal Consumer Credit Protection Law, will apply)EmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
