We offer a number of benefits to homeowners including:

  • Toll-free claims reporting available 24 hours a day, 7 days a week
  • Coverage for your secondary home, town home, or condominium
  • Guaranteed Replacement Cost coverage on most homes
  • Policies which are customized to fit your needs and budget
  • Additional coverages are available for your jewelry, computers, fine arts and other special items
  • Coverage for your in-home business

Please note that the results of this form will be sent via email. In the unlikely event that you encounter problems, please print your form and fax it to 1-800-847-3129.

GENERAL INFO *Required Field
First Name: *
Middle Name:
Last Name: *
Address: *
City: *
State:

*

Zip: *
Home Phone: *
Work Phone: Ext.

Fax:
Email Address: *
Best Time To Call: AM

PM
I prefer to be contacted at:
Occupation
Are you currently insured? Yes

No
If Yes, who is your current insurance carrier?
When does your current policy expire? (mm/dd/yyyy)
PROPERTY INFO
Location of Property (if different from your address shown above):
Year Built: (yyyy)
Amount of Dwelling Coverage: $

Deductible: $

Name of Fire District:
Distance to Fire Department: (required if rural)
Distance to Water Hydrant
Construction Type: Brick

Frame

Other
Please check all that apply. Farming on Premise
Trampoline
Swimming Pools
Central Alarm System
Wood Burning Stove
Date of Birth:
Social Security Number:
Year of Last Update For: Furnace
Electric
Plumbing
Roof
Any Pets or Animals? Yes

No
Comments and questions:
IMPORTANT: This information is requested for the sole purpose of creating your insurance profile. From this profile, we will generate insurance quotes by using the rating methods. When you submit this form, the information will be transmitted via email to our customer service department. If you are not comfortable in sending this information through email and the Internet, we suggest that you print the completed form and fax it to us at 1-800-847-3129. DISCLAIMER: By submitting this application to The Campbell Group, I hereby declare that the above statements are true. No coverage will be issued or bound until I receive confirmation from a licensed representative of The Campbell Group. I understand that this is a request for a quotation only and that I am under no obligation.