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Jeff Kaufenberg Agency
SmartInsurance.com

10788 SW Oriole Circle
Beaverton, OR  97007
Phone (503)-646-1174

Email: FarmersAgent@aol.com

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Homeowner and Renters Insurance Quote Request Page
Oregon and Washington Residents Only

The minimum requirements to receive your free home insurance quote is to want to insure a house within Oregon or Washington and complete all items marked with a *.

The more information you supply, the more accurate the quote. All quotes are subject to verification of all underwriting factors.

Basic Address Information

Name*
Address*
City*	Zip Code*	Date of Birth*

Please supply either a Daytime or Evening Phone Number Also the best time to call.*
Home Phone Number:
Work Phone Number:
Best Time To Call	Morning Afternoon Evening
E-mail Address:

Current Insurance Information

Policy Type Desired?
Homeowners Landlords Condominium Townhouse Renters

Current insurance carrier
(If you do not have a current insurance carrier type in NONE)

Policy Expiration Date/Premium Due Date

Amount of Insurance Desired

Dwelling Coverage (Amount of Insurance)

Separate Structures

Personal Property/Contents

Medical Payments

Personal Liability
(Bodily Injury and/or Property Damage)

Personal Injury Liability
(Slander,Discrimination,False Arrest,ect.)

Deductible

Number of Claims Filed Within the Past 5 Years
Please explain loss details, in the comments section below.

Additional Information/Comments

If you need any special endorsements (jewelry,guns,collectibles,furs,fine arts,ect.) or to clarify any items above: Please explain here.

Building Information

Year Built
Number of Stories.
Total Square Feet
Total Finished Square Feet
Construction Type (Ranch, 2 story, Split entry, Tri-level, ect.)
What Type of Roof do you have? (asphalt shingles, wood shakes, tar and gravel, tile, slate, ect.)
What is the Age of the Roof?
Garage Type/Size	Please select one No Garage Attached 1 Car Attached 2 Car Attached 3 Car Built In 1 Car Built In 2 Car Built In 3 Car Detached 1 Car Detached 2 Car Detached 3 Car
Number of Bathrooms
Number of Fireplaces
Does your home have a Deck?	Yes No
Do you have Monitored Central Burglar Alarm?	Yes No
Does your house have, Central Heating and Air Conditioning?	Yes No
Do you have a Swimming Pool?	Yes No
Is Flood Insurance Desired?	Yes No
If you have any other special features in your home, please explain in the comments section above.

Your request for a quote or the form

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If you feel uncomfortable sending the above information over the net, please call my office at: 503-646-1174 (Toll free at 1-800-285-2811).

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