Bleiler Insurance

Best Insurance Coverage | Allentown, PA

Bleiler Insurance

615 N. 20th Street,
Allentown, PA 18104

610-435-3802

info@bleilerinsurance.com

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Property Quote

Kindly complete this form and submit so we can prepare your home / landlord / vacant dwelling / mobile home insurance quote.

    General Information

    Name: *

    Mailing Address:

    City: State: Zip:

    Day Phone:

    Evening Phone:

    Best time to contact: AMPM

    E-mail address: *

    Occupation:

    Date of Birth:

    Current Insurance Section

    Company: (Not Agency, If no current insurance mark "none")

    Policy Expiration Date: (xx/xx/xxxx)

    Annual Premium:

    Property Information Section

    Property Location Address:

    City: State: Zip:

    Years Constructed:

    Square Footage:

    Approximate market value of dwelling:

    Property Style:

    Construction Material:

    Number of Families:

    Occupancy of Property:
    Primary HomeSecond / Vacation HomeRental PropertyVacant Property

    Number of stories:

    Is there a basement: YesNo

    Is the Basement Finished Living area: FinishedUnfinished

    Other Features (Check all that apply):
    Dead Bolts on Doors
    Smoke Detectors
    Fire Extinguishers
    Sprinklers
    Central Burglar Alarm
    Central Fire Alarm
    Solar Panels or Geothermal Heating/Energy
    Within 5 miles of Fire Dept.
    Within 1000 Feet of Fire Hydrant
    Wood / Coal / Pellet Stove
    Underground Oil Tank
    Tree House
    Jungle Gym / Swing Set
    Pond/Lake/Stream/River or other body of water
    Outdoor Hot Tub
    Swimming Pool

    Is Pool Completely Fenced with Locking Gate: YesNo
    Does Pool have a Siding Board: YesNo
    Does Pool have a Diving Board: YesNo
    Type of Pool: Above GroundIn Ground

    Trampoline
    Is it Netted: YesNo

    Home in a development: YesNo

    Property Update Section

    Roof

    Type of Roof:

    Roof Materials:

    Year Roof was last replaced:

    Heating

    Type of Heating System:

    Year Heating system was last replaced:

    Is there a secondary heat source: YesNo

    If Yes, Type:

    Electrical

    Type of Electrical Panel:

    Type of Wiring:

    Number of AMP:

    Year electrical was last updated:

    Plumbing

    Year water heater was last replaced:

    Year plumbing was last updated:

    Coverage Section

    Dwelling Amount:

    Other Structures:

    Personal Property:

    Loss of Use / Rents / Additional Living:

    Personal / Premises Liability:

    Medical Payments:

    Deductible:

    Additional Coverage: (Select all the ones you desire)
    Replacement cost on contents
    Replacement cost on Dwelling
    Sinkhole coverage
    Earthquake coverage
    Water Backup coverage
    Umbrella / Excess liability coverage
    Identity fraud coverage
    Special coverage for jewelry, fine arts, antiques, guns etc.
    Flood
    In home business coverage

    Additional Questions and Comments

    In order to provide you with an accurate quote the company will obtain your credit insurance score and additional reports to verify the driving records and claims history for the person / persons applying for the insurance. This will not have an effect on your credit history.

    *   I have read the Information Disclosure and accept the above terms and conditions

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    A Little About Us

    The Bleiler Insurance Agency is an independent insurance agency providing business owners and families throughout the Lehigh Valley located in Allentown, PA with the best coverage at competitive prices. We’re a family owned and operated agency in Lehigh Valley, PA with a well trained and experienced staff.

    Bleiler Insurance

    615 N. 20th Street
    Allentown, PA 18104

    Phone: 610-435-3802

    Email: info@bleilerinsurance.com

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    We serve the entire Lehigh Valley and surrounding areas including Allentown, Easton, Bethlehem, Whitehall, Northampton, Schnecksville, Macungie, Fogelsville.

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