Home Insurance Quote Form

Insurance for North Carolina
708 Spartanburg Hwy. NC 28792
(828) 692-8277
Fax:(828) 696-8181 Email
Hours: Mon. - Friday, 8:30 a.m. - 5:00 p.m.

Barnette and Coates Insurance, Inc.
Home Insurance Quote Application

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Complete & send the following form to obtain your FREE Online Home Insurance quote.

Your home is your largest investment. Make sure your home and belongings are covered against disaster, but be secure that you aren't paying more that you should for the right coverage. Receive premium discounts with your auto coverage too!

This insurance application will allow you to request a quote for Homeowners Insurance. When the form is submitted, the information will be sent to an agent in our office, who will generate a quote and email that information to you.

Be sure to have this information available in order to complete the application:
1. Address, including zip code, of the insured home.
2. Value of the home.
3. The year that the home was built.

Name

First name

Last name

Middle initial

Street address
Address (cont.)
City
County:
State
Zip/Postal code
Phone
FAX
E-mail

Zipcode of property:

Fire district & name:

Year of construction:

Type of construction:

Residence:

Value - dwelling only: $

Dwelling coverage: $

Do you want replacement coverage on the dwelling/contents?

Dwelling contents value: $

Use this space to enter any special comments you have
regarding the property to be insured:

How would you like for us to contact you? What would be the best time to contact you?

Zipcode of property:
Fire district & name:
Year of construction:
Type of construction:
Residence:
Value - dwelling only:	$
Dwelling coverage:	$
Do you want replacement coverage on the dwelling/contents?
Dwelling contents value:	$