Homeowners/Renters Insurance Quote

Thank you for your interest in Legere Insurance Agency.
Please enter the following information so we can respond to your request quickly and efficiently. Fields followed by an asterisk(*) are required information.
Note: We are licensed to sell insurance only in Massachusetts.

Contact Information:

Name: *
Street: *
City: *
State: *
Zip Code: *
Email Address *
Phone: *		Home    Business    Cell

Best way to contact you: *

Phone:   Time: Choose Time Mornings Afternoons Early Evenings  or Email:

Coverage Information

Coverage Start Date: *
Year of Construction:
Amount of Insurance: *
Deductible: *		-- Select -- $250 $500 $1000
Liability Limit: *		-- Select -- $100,000 $300,000 $500,000 $1,000,000 Higher amount, let’s discuss

Add Replacement Cost Coverage to Dwelling: *

Yes    No

Add Replacement Cost Coverage to Contents: *

Yes    No

Number of Families: *		-- Select -- 1 2 3 3+ (Tenants&Condo Only)
Construction: *		-- Select -- Frame (Wood) Masonry/Brick
Structure Type: *		-- Select -- Dwelling Condo Apartment
Occupied by: *		-- Select -- Owner Tenant
Usage: *		-- Select -- Primary Secondary Seasonal
Type of Heating: *		-- Select -- Oil Gas Electric Other
If oil, Location of Oil tank:

Any Liability or Property Losses: *

Yes    No

If yes, description of claim including date and amount paid:

Current Insurance Company:
Current Amount of Coverage:

Check all that apply:

Fire Alarm:		Alarm Company   Fire Dept.   At Home
Burglar Alarm:		Alarm Company   Police Dept.   At Home
Smoke Detector:		Alarm Company   Fire Dept.   At Home
Wood Burning Stove:		Yes   No
Swimming Pool:		Yes   No
		If yes: Diving board Fenced and secured Slide Retractable stairs
Trampoline on Property:		Yes   No
Any pets or animals:		Yes   No
		If yes: Type: Breed: Age: Years Owned:

How did you hear about Legere Insurance?

		-- Select -- Article in industry publication Advertisement (print) Yellow Pages Banner Ads Direct Mail Internet Search Newspaper Public Relations Web Site Link Word of Mouth
Other:

Would you like to subscribe to our online newsletter?

Yes    No