Home Quick Quote

Complete this quick quote form to provide J. Archer Insurance Group with essential details about your home and coverage needs. Type N/A where fields don't apply.

Return completed form by email to service@archerinsgroup.com.

Works on any phone, tablet, or computer — no app needed. Type N/A where a field does not apply. Fields marked * are required.

Applicant / Named Insured

Date Needed / Due *

Desired Effective Date

How Did You Hear About Us?

Referred By (name)

Applicant Information

Applicant — Full Legal Name *

Date of Birth

Marital Status

SSN (optional)

Driver License # / State

Occupation / Profession

Employer

Cell Phone *

Co-Applicant / Spouse Information

Co-Applicant / Spouse — Full Legal Name

Date of Birth

Marital Status

SSN (optional)

Driver License # / State

Occupation / Profession

Employer

Cell Phone

Mailing Address

Apt / Unit

City

State

ZIP

County

Time at Current Address

Prior Address (if < 3 yrs at current)

Preferred Contact & Best Time

Any property held in an LLC / Trust?

If yes, entity name(s):

Property

Is the property the same as the mailing address above?

Property Address

City

State

ZIP

County

Property Details

Occupancy

Residence Type

# Families

Year Built

Living Area Sq Ft

Fin. Basement Sq Ft

Construction

Foundation

Roof Material

# Stories

Roof Shape

Protection Class

Dist. to Fire Station (mi)

Dist. to Hydrant (ft)

Nearest Fire Station

Utilities & Systems

Water Heater Age

Water Heater Location

Dog Breed / Exotic Pets

Yr Roof Updated

Yr Wiring Updated

Yr Plumbing Updated

Yr HVAC Updated

Yr Electrical Updated

Property Features

Solar Panels

Swimming Pool

Pool Fenced

Auto Water Shut-off Valve

Generator

Alarm / Monitoring:

Wood / Pellet Stove

Trampoline

Business on Premises

Insurance History

Dist. to Coast / Tidal Water (mi)

Prior / Current Carrier

Yrs with Prior Carrier

# Claims — Prior 5 Yrs

Home Coverage

Current Policy

Current Carrier

Current Premium

Policy Expiration

Yrs with Carrier

Policy Form

HO3 (Homeowners — standard) HO5 (Premium / open peril) HO4 (Renters) HO6 (Condo) DP3 (Rental / dwelling — special) DP1 (Rental / dwelling — basic)

Coverage Amounts $

Dwelling (Cov A) $

Other Structures (B) $

Contents (C) $

Loss of Use (D) $

Deductibles & Liability

Personal Liability

Medical Payments

AOP Deductible

Wind / Hail Deductible

Flood Coverage

Flood coverage in force?

Building Flood Limit

Contents Flood Limit

Flood Carrier (NFIP / private)

Mortgage & Lender Information

Mortgage? Lender / Loan #

Additional Interest / Mortgagee

Is this for a closing / new purchase?

Closing / funding date:

Lender insurance requirements, if any (dwelling amount, replacement cost, escrow, etc.)

Any lapse in coverage (last 5 yrs)?

If yes, details:

Documents to Submit

Attach with this form:

Current policy declaration pages Appraisal(s) (if available) Photos of home Home inspection(s) (if available) Claims / loss report (last 5 yrs)

Loss History

Last 5 years

Describe all home claims / losses: date, type, amount, and status.

Authorization & Return

Broker of Record / Exclusive Representation Acknowledgment *
I authorize J. Archer Insurance Group to market my account and act as my exclusive broker for this submission. I understand that duplicate submissions by other agents can cause carriers to block access and delay or jeopardize the best available pricing.

Applicant Signature (type full name) *

Date *

Print Name & Title

Tap Submit to send your answers to our team, or Save / Print as PDF to keep a copy and email it to service@archerinsgroup.com. Questions? Call 281-501-8331.

What Happens Next

Your dedicated Personal Lines & Private Client team will review your submission and work with top carriers to find the best coverage options and rates for your home.