Full Name:

Spouse's Full Name:

Street Address:

City: State: Zip:

Contact Phone Number(s):

Best Time to Call: Morning Evening Anytime

Fax Number (Optional):

E-mail Address:

How do you prefer to receive your insurance quote?
Phone Fax Email

Current insurance company if any? Policy Expiration:


Current deductible:

Current limit of liability:

Year home was built:

Construction (wood frame, brick, stucco):

Renters or condo owners limit of property insurance:

Is there a mortgage? Yes No

Do you wish to schedule any valuable articles? If so, please indicate the amount of coverage in the box to the right of each desired category:

Fine Art:
Jewelry:
Furs:
Guns:
Silver:
Stamp or coin collections:

Notice: Social Security Number - Most insurance companies engage in "insurance scoring." A credit inquiry is done by the company as a factor in pricing. For your privacy, we prefer to get this information by phone, fax or email. Please let us know in the remarks section how you prefer to provide us with this information. If you prefer not to give this information, we understand and will provide the most competitive quote possible without it.

I will call (303) 444-3334 to provide it now.
Please call me upon receipt of this quote
I will fax it to (303) 444-2716.
I will email it to info@rickbakerinsurance.com.
I will not provide my SSN. Please quote without it.