24 E Broadway Rd Ste 2   Phoenix, AZ 85040  Tel: (602) 200-0062
AZ Unified Insurance Agency LLC
Home Insurance Quote Request Form
Personal Information
Property Information
First, Middle, Last
Street Address
Date of Birth
City, State, Zip Code
Mailing Address
County
City, State, Zip Code
Year Built
Sq.Ft.
Contact Information
# of Stories
# of Families
Type of Coverage:
Home Owners Policy:
can  only be issued when the owner of the property occupies the house
A Fire Dwelling Policy: Will be issued to cover the building structure only (not contents) when house is occupied by
other than the Home owner or when the home owner, occupant of the home elects to do like so.
If you are a
tenant looking to cover your contents in the building you are renting you need Renters Insurance
Type of Coverage
Home occupied by:
1. Will you occupy the dwelling as your only primary residence within 10 days of inception of coverage?
Yes
No
2. Will more than one (1) family occupy the dwelling or unit?
Yes
No
3. Is the dwelling within 1,000 feet of native brush, or isolated or inaccessible to fire fighting equipment?
Yes
No
4. Does the dwelling have a permanently installed space heater that was not professionally installed or
a wood, coal or kerosene stove as primary source of heat?
Yes
No
5. Does the dwelling have the minimum number of smoke alarms required by law and deadbolts on all
standard doors that provide access to the dwelling or garage?
Yes
No
6. Does the dwelling have fuses providing power to any portion of the dwelling?
Yes
No
7. Do you understand that animal liability is excluded for all policies, unless optional animal liability
coverage is purchased?
Yes
No
8. Does the applicant have any repetitive similar cause losses, or more than two (2) cancellations for
non-payment with Pacific Specialty within the last three (3) years?
Yes
No
9. Does the applicant have more than three (3) losses or any kind, or more than one (1) theft loss within
the last three (3) years?
Yes
No
The submission of this document will be saved and attached to Home insurance application if coverage is purchased by you.
Please fill as much information as possible
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or Print and fax  to : 602 200-0063