Joseph S. Hills Agency, Inc.

Office Location:
     129 Main Street
     PO Box 300
     Plaistow, NH 03865-0300

Telephone #:
     603-382-9211 or
    800-295-9211
FAX #:
     603-382-3387

Emergency contact # 877-487-9339, leave your name & number with the operator

On-Line Applications Home Page Privacy Notice

Homeowners Insurance Quote Form

NO OBLIGATION COMPARISON QUOTE - Only complete this form if your house is located in the state of New Hampshire. After submitting the requested information, the Hills Insurance Agency will calculate the quote for you.

All information will be kept completely confidential.

HOWEVER, NO COVERAGE IS BOUND AND THE QUOTE IS SUBJECT TO AN INSPECTION AND OTHER UNDERWRITING CRITERIA.

To ensure an adequate comparison quote, please enter the following information with your current policy in front of you:

Your full Name:
Your Mailing Address:
Property Address:(if different)
Town: State: Zip:
Home Phone Number: Work Phone Number:
Best Time to Call:
Your E-mail Address:
Is this your
Amount of Coverage on Dwelling:

Deductible

Liability Limit

Replacement cost coverage on the Dwelling?
Replacement cost coverage on Contents?
Year your house was built: Square Feet of your House?: (width x length, if known)
Number of Stories: Occupancy: Construction:
Basement: # Full Baths: # 1/2 Baths: # Chimneys:
Garage:
Decks/porches: describe size
Any detached structures? describe size

If your house is over 20 years old, please complete the following:
Age of Roof (Enter the year):
Age of Furnace (Enter the year):
Age/Condition of Plumbing (Enter latest update year & describe)
Age/Condition of Wiring (Enter latest update year & describe)

List all Pets Owned, or enter "None". If dog(s), please list breed and if any biting history

Please enter any claims you have had in the past 5 years, even if at a different home. Include the date, brief description of the incident and the amount of the claim, or enter "None".

Is there a pool on the premises?     Type

Any Business conducted on the premises? No Yes, describe
Any Daycare provided at your residence? No Yes
Primary Heat Source Is there a Woodstove
Where is your oil tank located?
Is there a trampoline on the premises?
List any scheduled items (rings, furs, fine arts, etc.)
            Item                                              Value

Any computers used in business kept at your residence?

Do you have any of the following:

smoke detectors           deadbolt locks on all exterior doors
fire extinguisher            local alarm system
central alarm system

Are you a household?

Your Current Insurance Company:

Expiration date of current policy:   Premium: $
If you are just purchasing the home, what is your closing date?
What is the Purchase Price? (optional) $

Extra Comments:

Was your existing policy in front of you in order to ensure an
adequate comparison quote?   YES       NO

Did you complete all the information?

How did you find our web site?

Thank you for taking the time to complete this online Homeowners quote form.

How you would like to be contacted to receive your quote:

When completed, click on Submit Request ONE time and we will forward your quote to you in the form you have requested. If you have any questions, please feel free to contact us at 603-382-9211 or 800-295-9211

    General Information: info@hillsinsurance.com
    Sales: Dave@hillsinsurance.com
   Webmaster: Sharon@hillsinsurance.com

Any requests to add or change coverage will only be bound when confirmation notice from our office has been sent back to you either by phone, e-mail or mail.