Dewey Insurance Agency, Inc.               www.deweyinsurance.com
9050 Pines Blvd. #340                      Phone: Broward: 954-436-5630
Pembroke Pines, FL 33024                    Dade: 305-945-6955
                                             Fax: 954-436-6572

   Home Quote Form                       Please Type Or Print Clearly
  -----------------                     -------------------------------


          NAME: ________________________________________________________
                (First, Middle Initial, Last)

         TITLE: ________________________________________

  ORGANIZATION: ________________________________________

STREET ADDRESS: ________________________________________

      ADDRESS2: ________________________________________

          CITY: ____________________    ZIP/POSTAL CODE: _______________

        COUNTY: ______________________________________
                (South Florida Only)

    WORK PHONE: ____________________    HOME PHONE: ____________________

           FAX: ____________________        E-MAIL: ____________________


DO WE HAVE PERMISSION TO OBTAIN A CREDIT
         SCORE FOR YOU TO AID IN RATING?: yes___  no___

  SOCIAL SECURITY NUMBER: _______________________________________

REPLACEMENT COST OF HOME: ____________

   YEAR HOME BUILT: ____/____/____/

    SQUARE FOOTAGE: _____________       CONTENTS COVERAGE: _____________

LIABILITY COVERAGE: _____________             DEDUCTIBLES: _____________

   EXPIRATION DATE: ____/____/____/

CURRENT HOMEOWNERS INS. CO.: ____________________________________________

IS YOUR HOME IN A GAITED COMMUNITY?: yes___  no___

     ALARM SYSTEM?: yes___  no___

   STORM SHUTTERS?: yes___  no___     HEATING SYSTEM?: yes___  no___

CLAIMS IN THE LAST 3 YEARS: ___________

   DO YOU OWN ANY ANIMALS?: yes___  no___

  TYPE AND SIZE OF ANIMALS: ____________________________________________