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Please complete the information requested below as accurately as possible, and upon your submission a DFBENEFITS representative will contact you within two business days to provide your quote.

If you wish to speak to a DFBENEFITS representative directly, please call our Personal Insurance Division at (800) 538-6040.

* Required fields

Name*

Employer/Occupation

Email Address*

Mailing Address*

City*

State*

Zip Code*

Date of Birth
/ /

Daytime Phone*

Present Insurer*

Annual Premium*

Current Dwelling Amount

Deductible*

Any claims in the past 3 years?* No Yes  

Year built*

Current market value

Construction type* (ie. Brick, Stone, Frame)

Total square footage

Number of stories*

Home specifications*

Basement

Unfinished Basement

Crawl Space

Slab

Finished Basement

Fireplace

Central Air Conditioning

Wood Stove

Pets
Yes   No

Trampoline
Yes   No

Number of full baths*
Select - 1 2 3 4 5 6

Number of 1/2 baths*
Select - 1 2 3 4

Garage*
Attached   Detached   None

Size of garage
Select - 1 Car 2 Car 3 Car

Alarm System?*
Yes   No

Fire Extinguisher*
Yes   No

Deadbolt Locks*
Yes   No

Non-smoker*
Yes   No