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		231 Hudson Avenue   •   Newark  OH  43055 (740) 345-1916   •  (740) 345-3031   •  Fax: (740) 345-3031     On-Line Service Center Homeowner's Quote Request We cannot bind coverage from an email or voicemail request. Coverage is bound after you receive a written email or telephone confirmation from an agency staff member.   Effective Date: Your Name: Your Mailing Address: Street City & State                                                     Zip    E-mail Address: Daytime Phone #: Choose One: Please call me with quote premium. Please send quote via e-mail. Current coverage: Company:                                       Expiration Date:   Type of policy desired: Homeowners Insurance Condominium Insurance Renters Insurance   Amount of insurance desired: Homeowners only: What is the value of your home? Condo/Renters only: What is the value of your personal property? Liability Limit: $100,000 $300,000 $500,000 Medical Payments: $1000 $5000 Valuation of Home: Actual Cash Value Replacement Cost Personal Property Valuation: Actual Cash Value Replacement Cost Deductible: $250 $500 $1000 Property Information: What is the construction type of your home? Frame Masonry In what year was your home built? In what County/Township are you located? Distance to the nearest fire hydrant? Less than 500 ft. Over 500, under 1000 ft. Over 1000 ft, under 3 miles Over 3 miles What kind of pets do you have? Do you have a swimming pool? Yes No Do you have a trampoline? Yes No Do you use a wood burner? Yes No Smoke Detector(s) Installed Home Security System Installed   Home Updates:  Enter year updates were made. If year not known, enter "unknown": Roof: Wiring: Plumbing: Heating: Optional Property Coverages: Earthquake Coverage Requested Flood Coverage Requested Sewer/Water Backup Coverage Requested Property Floaters - Indicate limits below: Antiques: Coins: Computers: Fine Arts: Furs: Jewelry: Stamps: Tools: Other Floater Coverage:     Limit of Insurance:   Previous Loss Information Please describe any losses or claims filed on your Homeowners Insurance in the last 3 years: Date of loss:               Type of loss:                                                Amount of claim: Additional Comments Please use the box below to enter any additional information you wish to include:          If you have not received a response from us within one business day, please contact us again. Thank you. Return To Service Center Forms Page Campbell Agency, Inc.  231 Hudson Avenue Newark, OH 43055  Phone:  (740) 345-1916 Phone:  (740) 345-3031 Fax: (740) 345-3031  Copyright © Campbell Agency, Inc., 2003 campbellinc@adelphia.net