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With LeadExchange™ working for you, you'll have confidence that the leads that your web site produces are only from interested consumers.  Below you'll find a sample Homeowners Insurance lead.  All consumers are required to fill out a standardized questionnaire in order to be considered a valid lead.  To return, please click here

What does homeowners insurance cover?

Homeowners insurance provides protection for your home, personal property such as furniture, clothing, appliances as well as for personal liability. It protects you from a variety of events, including fire, lightning, burglary, vandalism, storms, explosions, and more..

Instructions:  Please fill in this form as completely as possible in order to ensure that your quote will be as accurate as possible.

First Name


Last Name


Street Address






Zip Code


Day Phone


Evening Phone


E-mail Address


Best time to call:


Who is this quote for?




What month did you buy your home in?


Purchase Price (or) Replacement cost of your home:


Type of Home


Year Built


Square Feet


Electrical System


Type of Construction


Do You Have An Alarm?


Do You Have Central  Air


Number of Fireplaces


Number of Bedrooms


Number of Bathrooms


Do you have a pool?


Garage Type


Have You Made A Claim  In The Past 5 Years?


Your Current Fire/Home  Insurance Carrier: (Leave blank if you have none)


Would you like an additional quote for any of the following insurance products?

 Life Insurance
 Annuities (Retirement Vehicle)
 Disability Insurance
 Long Term Care Insurance
 Health Insurance
 Group Health Insurance
 Auto Insurance
 Home Loans