HOMEOWNER / PRINCIPAL PRIMARY RESIDENCE

Please complete this form if you are seeking a quote on your Principal primary residence that you now, or will soon occupy. Please note that by completing this form you are not applying for insurance or requesting coverage at this time. Your information will be sent to a licensed agent or broker for evaluation and quotation. The information that you provide is confidential and will not be shared with others except possibly Insurance Company underwriters in the case of our agency requesting some type of evaluation from a company underwriter. If your request for an insurance quote is for Arizona, California or Nevada, you can get an instant indication online.

However, we use this online service primarily for those that want to have a means of sending us the data so that we can then speak with them about their specific insurance needs. It is kind of like when you go to the doctors, he is going to gather information from you and give you a check up. We hope you are healthy! Thank you for Choosing Athena Insurance and Financial Services. Have a nice day. Remember we are just a phone call away (888-299-1870.

First name Middle Initial Last name        DOB  
Second name if applicable Middle Initial Last name        DOB
Cell Phone Home Phone email
Current mailing address street City State Zip
PROPERTY / DWELLING INFORMATION  (check if the same )
Physical Location of dwelling City State Zip
Year Built Age of roof Roof Material Alarm?
Condition of Roof Construction Type Ave Wall Height Sun lights
Exterior wall covering Attached Garage    No. cars Other Detached buildings Wood Stove
Square footage of living area  Basement    if yes, SF Acreage Smoke Detectors
Number of stories # full baths   # half baths Kitchen jacuzzi
Swimming Pool    if swimming pool, is there a diving board?  Any animals if yes describe quantity and breeds
Remarks / Comments       Fire place(s)        How many
Any Claims within the last three years?   if yes, please describe and provide dates
Is there a fire hydrant within 1000'?    Is there a fire department withing five miles?    
EMPLOYMENT INFORMATION (your information is confidential)
First name employer Address State zip

Other Owner employer

Address State zip
If you are interested in receiving a qute with added discounts please check all that would apply. Remeber we are only a phone call away 888-299-1870
Senior Citizen Discount*

Please be sure to ask about a full service review.  Classic autos are not protected under home policies. Nor are motorcycles or other recreations vehicles.  Many individuals need a personal catastrophy umbrella policy. Ask your agent for more information.Need a health quote.. we can help.  We have it all.  Make the wise choice. 

Multiple policy discount car and home*
Gated Community*
Loss free for five years plus*
Please provide the name of the Athena Insurance Representative or Agent or Source of referral. Thank you.    
* Not all carrier offer all types of discounts.  We will do the comparison shopping and discuss some carrier options with you.