Quick Quote Homeowner Insurance from: State Farm Insurance - Mike Miller
827 N. Last Chance Gulch, Helena - 406-442-9900
Today's Date:	MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember  Day01020304050607080910 1112131415161718192021 22232425262728293031  Year060708
Your First Name:
Middle Initial & Last Name:
Date of Birth:
Marital Status:
Spouse Full Name:
Date of Birth:
Street Address:
City:
State:
Zip Code:
County:
Phone Number where you would like to be contacted:
Best time to reach you?
Email address to send information:
Do you own your home or do you rent?	Own Rent
Is this a Home, Condominium, Townhouse or Other unit:	Home Condominium Townhouse Other
General Information about your Home:
Year of Construction of home:
Total Square Feet:
Style of home:
Type of Garage:
Is the garage attached or detached from your home?	Attached Detached
Is there a built in living space above the garage?	Yes No
Is this a normal tract home, or is it custom built?	Normal Tract Custom
How many full baths?
How many half baths?
How many fireplaces?
Roof type (I. e. wood shake, etc.)
Exterior of home (I. e. stucco, etc.)
Is there a burglar alarm?	Yes No
Is there a separate Jacuzzi/hot tub?	Yes No
Wet bar?	Yes No
Are there fire sprinklers in the attic?	Yes No
Is this a new home purchase?	Yes No
If yes, escrow close date?
Policy Information:
Name of current insurance carrier:
Renewal date?
Number of Losses in the past three years?
Amount paid, if known:
Non-smoker?	Yes No
Are you over the age of 50?	Yes No
Do you have an Umbrella liability policy?	Yes No
Auto Carrier?