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Homeowners Policy Request

You may use the form below to submit an homeowners policy request directly to our qualified agents. We will contact you shortly after receiving the request. No changes will be bound until you recieve confirmation from our office upon review.

Type of home
City State Zip
Home Phone Work Phone
Present insurance Co. Expire Date
Amount of Coverage
Age of house Age of roof
Occupation Years at present job
How long at this address No. of claims in last 3 years
Type of house? 1 Story2 StorySplit Level
Construction type? Frame/StuccoMasonrymasonry veneer
Square footage?
Roof type? Asphalt/ShingleTitle/SlateOthers
Do you have a garage? 1-Car2-Car3-CarNone
Garage type? AttachedDetachedBasement
Are you in a high brush area? YesNo


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The Shannon Agency
Timothy G. Shannon, CLF, AIM, LUTCF

Phone: (800) 999-5729
Fax: (877) 625-9370