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phone

Main-574.234.2464
Fax-574.289.1257
Toll-877.237.4346

address

2516 Mishawaka Ave
South Bend IN 46615

Peterson Insurance: Home Quote
Questions marked by * are required.
1.	Hello! We wanted to let you know that your information is PRIVATE and will not be sold to third parties. We are asking for your PRIVATE information in order to obtain the best possible quote for you. Please look for the secure forms icon in your browser before completing any online forms. If you have any questions, please don't hesitate to contact us at 574-234-2464. Thank you for the opportunity to earn your business. Please indicate your preferred method of contact. Sincerely, Peterson Insurance Agency. Email Mail Phone
2.	Name *
3.	Email *
4.	Phone
5.	Address
6.	City/State/Zip
7.	Date of Birth
8.	Current Insurance Company
9.	Claims in last 3 years None 1 2 3 or more
10.	Type of policy you need Homeowner Renter Condo Owner Landlord
11.	Year Home Built
12.	Number of square feet
13.	Home style 1 story 2 story Tri or Split Level Other- explain below
14.	Garage or Carport None 1-car garage 2-car garage 3-car garage Detached garage Other- explain below
15.	Number of FULL bathrooms 1 2 3 or more
16.	Number of 1/2 or 3/4 bathrooms 1 2 3 or more
17.	Type of roof Flat Asphalt Shingle Tile Wood Shingles Other-explain below
18.	Exterior Wall Frame Stucco Brick Wood Siding Aluminum Siding Other-explain below
19.	Fireplace Yes No
20.	Deck Yes No
21.	Patio Yes No
22.	Deadbolts on all doors Yes No
23.	Smoke alarms Yes No
24.	Fire Extinguisher Yes No
25.	Monitored Security System Yes No
26.	Contents Coverage Amount (if known)
27.	Additional Comments
28.	Please note: Please remember coverage CANNOT be bound over electronic communications. You must speak with a representative of the Agency. For immediate assistance don't hesitate to call us at 574.234.2464. Agree Disagree

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