Padgett Insurance Agency PO Box 1119 Richmond Hill, GA 31324
11258 Ford Ave Suite 2 Richmond Hill, GA 31324
Phone: (912) 756 - 6394 Fax: (912) 756 - 2804 Email Us
Fields marked with * are required. When you have completed filling out the form, click the SUBMIT button. All information provided is confidential and will be used solely for the purpose of providing a quote for you.
*Applicant's Name:
*Phone:
*Email:
*Mailing Address:
*Mailing City:
*State:
Zip:
*Property Address: (if different than mailing)
* City:
Currently insured?
Yes
No
If yes, with what company?
Policy expiration date:
If no, reason:
*Dwelling Value:
*Personal Liability:
*Medical Payments:
Deductible:
Structure type:
Usage type:
Square Feet:
Year built:
Roof material:
asphalt shingles metal tile tin
Distance to fire station (in miles):
Distance to fire hydrant:
less than 500 feet 501 - 1,000 feet 1,001 feet or more
Name of servicing fire department:
Construction Type:
Within city limits:
Rating Credits - Check all that apply:
deadbolt
fire extinguisher
smoke detector
burglar alarm
House is for sale?
Swimming pool on premises?
If pool, is it fenced?
If pool, is there a diving board?
Farming or other business conducted on premises, including daycare?
Any coverage declined, cancelled or non-renewed in last 3 years?
Has applicant had a foreclosure, repossession, bankruptcy, judgement or lien during past 5 years?
Are there any animals or exotic pets kept on premises?
Trampoline on premises?
Please review your entries for accuracy before submitting your request. Please note: This is only a quote does not bind coverage. Quote is subject to credit check and additional underwriting.
