Ackley-Peters-Haubert Insurance

IMPORTANT: READ THIS PRIOR TO CONTINUING.
No coverage is bound and any quote is subject to inspection and other underwriting criteria.
We can offer you the most savings by packaging home and auto insurance.
IT IS HIGHLY RECOMMENDED THAT YOU ALSO HAVE US QUOTE YOUR HOME INSURANCE.
When you are done with this, please get your auto insurance policy and go to our auto insurnace quote request.

You can also download this form

Your Name:
Address:
City:
Zip Code:
E-mail:
Home Phone:		Work Phone:
Cell Phone:		FAX:

County (not Country):		Responding Fire Dept:
Miles from Fire Dept:
Is there a fire hydrant within 1,000 feet Y or N?		No Yes
Birthdate of oldest member of household?		(mm/dd/yy)
Your occupation & employer:
Your spouse's occupation & employer:
What is your home currently insured for?:

Deductible(Click to highlight deductible wanted):
Liability Limit (Click to highlight limit wanted): Ask us about Umbrella Liability and the discount available
Guest Medical Payment Limit:
Approx. Sq. Ft of your house:
Construction Type:	Frame Brick
If Brick, what percentage is brick?:
Year your house was built:
Age of roof (Enter the Year):
Age of furnace (Enter the Year):
Age/Condition of plumbing (Enter latest update year & describe)
Age/Condition of wiring (Enter latest update year & describe)
Who will be/is living in the house?
List all pets owned or put "none". If dog(s), please list breed
Do you own now, or do you plan to get trampoline?		Yes No

Homeowners policies from most companies exclude damage from any type of water in the home including backup of water through sewer, sump pumps or drains. Some companies let you add additional coverage to add limited coverage for backup of sewer, sump pump or drains.
Are you concerned about this? No-don't care Yes, I want coverage Maybe-depends on cost.

Please describe any and all claims you have had in the last 5 years on a homeowners or renters policy--even if it was a different home. Include amount of claim and approx. date. If none, then type in "none":

Does ANYONE in the household smoke?:			Yes No
Do you have smoke detectors?			Yes No
Do you have at least one fire extinguisher?:			Yes No
Do you have deadbolt locks on ALL doors leading outside?			Yes No
Do you have an alarm system?			Yes No
Do you have a wood burner?: (fireplace is NOT a woodburner)			Yes No
Do you have any recreational vehicles, sporting equipment, or watercraft?			Yes No
Do you have any high valued jewelry, art, collectible's, guns, computer equipment, etc?			Yes No
Do you operate a business from your home?			Yes No

What company currently insures your Autos?:

Extra comments:
How did you find our site? If "Other search engine" or just "Other", which search engine or where?
Please let us know how you would like us to send you the quote:
Phone Call Email Fax U.S. MaiL
If you entered "phone call", what is the best time to call? Thank you for completing our online quote form.