Pavlos Panagopoulos Insurance Agency
HOMEOWNERS INSURANCE
QUOTE QUESTIONAIRE
Please fill out form. we will mail your quote ASAP.

Note: For an accurate quote please provide us with a copy of your prior insurance policy, this will
                           help us serve you better.

   If you have any questions, feel free to contact us at (505) 864-6675.  Ask for Pavlos, Raelynn or
                                Francine.


 
First Name
Last Name
Physical Address

Mailing Address
(if different from Physical)

Home Phone
Work Phone
Email
Number of Stories 1  2 3 4 5
Frame Wood  Steel Masonry
Number of Families
Attic Yes  No  Square Footage
Basement Yes  No  Square Footage
Square Footage of Front Porch
Square Footage of Back Porch
Year Built
If over 30 years please 
provide when updates
took place on		 Year Built
Plumbing
Wiring
Heating
Roof
Alarm Yes  No
If Yes,
Central Station
Monitored
Local
Deadbolt Yes  No
Smoke Detector Yes  No
Fire Extinguisher Yes  No
Second Story or Higher Balcony Yes  No
Number of Fireplaces Hearths
Chimneys
Gas
Number of Rooms
Number of Baths (include fractions)
Garage Yes  No
Attached  Detached
1 car
2 car
3 car
4 car
Square Footage of Garage
If No Garage, Carport Yes  No
Square Footage of Carport
Airconditioning Evaporative
Evaporative Using Heating Ducts
Not Evaporative Using Separate Ducts
Heat type
Square Footage of Home
Distance to Hydrant Ft.
Distance to Fire Dept. Miles
List all Losses/Claimes
whether or not paid in
the last 5 years
Deductible Options $250  $500  $1000  $2500  $5000
 
Current Dwelling Amount
Market Value
Loan Amount
BACK