Burns Insurance Agency, LLC 
500 South Central Avenue 
Marshfield, WI 54449 
715-387-0002 
     

Homeowners Insurance Quote Request
Please complete the form below and click on the button labeled 'Submit Quote Request'.  Since our Internet quote forms do not ask for confidential information such as Social Security Number, an agent may contact you to obtain more information when putting together your quote.

If you have any questions or would like an immediate quote, please contact one of agents at insure@burns-insurance.com.

Please note that any fields followed by ** are required.
  

PERSONAL INFORMATION
First Name: **
Last Name: **
Address: **
City: **
State: **
Zip Code: **
CONTACT INFORMATION
Phone: **
Fax:
Email: **
CURRENT INSURANCE
Current Company:
Current Premium:
Has your insurance been cancelled or non-renewed?
   		Yes  No
Have you ever filed a claim against your homeowners policy?
   		Yes  No
If yes, please explain:
RESIDENCE INFORMATION
Is the address to be insured the same as above?
  
If Not:		 Yes  No
Address:
City:
State:
Zip Code:

What is the construction of your home?
  
What year was your home built?
  
What is the total square footage of your home?
  
Select any of the following that apply:
   		Smoke Detectors Fire Alarm Burglar Alarm

Do you have a business in your home?
  
Yes  No
Additional Information:
INSURANCE REQUIRED
Dwelling Limit:
Deductible:
Personal Liability Limit:
Do you have any pets? Yes  No
If yes, please describe:
RETURN OPTIONS
Please email the quote to me.
Please fax the quote to me.
Please mail the quote to me.
Please call me.
  

 

 

 

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