
	Personalized insurance services for over 30 years... Serving all of Orlando & Central Florida Communities.	2 Locations Dr. Phillips-Orlando, FL Winter Park, FL

Home Insurance Quote

Prefer to talk to an agent?
Call us anytime at
407-855-1000

Please complete the following survey as completely and accurately as possible. Once the information is submitted we will expedite your request and contact you via your selection. This information will be kept confidential and will be used for quote purposes only. We at Harry Levine Insurance look forward to serving you.

Customer Information

First name *

Last name *

Contact number *

- -

How may we contact you *

Date of birth

/ /
(example: 10/15/1962)

Street *

Apt

Home status

ZIP Code *

City *

State *

Insured for the last 6 months?

Yes

Insuance Company

We occasionally send out a newsletter via email regarding new products and information from Harry Levine Insurance & Financial Services.

Yes

Current Policy Information
Current Insurance Policy:
Policy Expiration Date:
Home Value to be Covered: OR Renter's Contents:
Deductible: ($100, $250, $500, Other)
Liability Coverage: ($100,000, $300,000, Other)
Current Annual Premium:
# of Claims in Last 3 Years:

Property Information
Is Location to be Insured Same as Above:	No Yes
If 'No' Above, Please Complete Location Information:	City: State: Zip:
Ownership:	Own Rent
Home Use:	Primary Residence Rental
Property Is A:	Home Condominium* Townhouse Apartment * If Condo - Number of Units in the Building
How Long at Present Address:	Years Year Home Was Built
Age of: (years)	Roof Wiring	Heat Plumbing
Fire Department Name: Miles From Dwelling: Nearest Fire Hydrant:	Miles Feet

Structure Information
Type	Construction	Roof	Foundation	Garage

Sq. Ft.: (excluding basement & garage)

Features
Bathrooms	Basement	Deck/Porch/Patio	Fireplaces
# of Full: # of Half:	Sq. Ft.:	Deck Sq. Ft.: Porch Sq. Ft.: Screened Patio Sq. Ft.:	# of Chimneys: # of Fireplaces: Woodburning Stove: No Yes
Swimming Pool	Trampoline	Pets	Scheduled Property
	No Yes	# of Pets: Claims?:	Personal: Computer: Office Equip:

Security/Systems

Heating System

Central Air

Dead Bolts

Security Alarm

Fire Alarm

Smoke Detector

No
Yes

Extinguishers?
No Yes

No
Yes

Additional Considerations/Requests

Additional comments you feel necessary for this quote

Prefer to talk to an agent?
Call Harry Levine Insurance anytime at:
407-855-1000

Click on the "Submit" button to send your quote request.
Thank you

Protecting your privacy is very important to us. Policyholders like you have trusted us with their insurance needs for over 30 years, and we take our obligation to safeguard and secure your personal information very seriously. Unless you expressly give us permission to do so, or unless required by law, Harry Levine Insurance & Financial Services does not disclose your unique personal information other than for the sole purpose of insurance quotations at your request.

EMAIL ADDRESSES: Your email address shall only be provided to our agents, brokers and/or companies who receive your data so they may confirm, respond and communicate with you. We will also send you a confirmation email after submitting your information for a quote. WE DO NOT SELL OR DISTRIBUTE YOUR EMAIL ADDRESS.

Current Policy Information

Property Information

Structure Information

Features

Security/Systems

Additional Considerations/Requests