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Berkshire Hathaway HomeServices Fox & Roach - Insurance Request Form


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Berkshire Hathaway HomeServices Fox & Roach - Insurance Request Form
Who is completing the form?
First Name
Required
Last Name
Required
E-Mail Address
Required
Property Information:
Location Address Being Purchased:
Required
ZIP / Postal Code
Required
Please provide the full name of each person listed on the deed of the property:
Required
Who will occupy the property?
Required
What is the approximate move in date?
Required
/ /
Do you own any pets?
Required
If Yes, what breed(s) and is there a bite history?
Optional
Will there be a trampoline on the premises?
Required
If Yes, will there be safety netting?
Optional
What are the values of your valuable personal possessions, such as jewelry and artwork?
Required
Are you planning to install/activate a central station burglar and fire alarm system within 30 days after settlement?
Required
1st named Buyer's Occupation, Date of Birth, and Education Level:
Required
2nd named Buyer's Occupation, Date of Birth, and Education Level:
Required
By packaging your home and auto insurance, we can provide you with the best insurance policies at the most competitive pricing!
1st named Driver's name that appears on driver's license and license number:
Optional
2nd named Driver's name that appears on driver's license and license number:
Optional
Please provide the same information for all other drivers residing in your household (including birthdates):
Optional
Who is your current Auto Insurer and how many years have you been with them?
Optional
Please provide the Year, Make, and Model of your vehicle(s):
Optional
Uploading a copy of your current auto policy will allow us to evaluate your current coverages as well as to provide us with your VIN(s).
Optional
Submission Validation
Required
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

Raving Fans

Thank you so much for all the time and careful explanation you shared this morning --- You are SO knowledgeable and well spoken!

I have alerted State Farm that I have found a superior company/policy. So, let's proceed with our plan to begin coverage on Monday, July 22!

Many, many thanks again, Julie!

Cynthia Pierce

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