Companies We Represent

The single biggest investment you may make in life is your home.  The McCoy Agency will assure that your home is properly protected.   Please complete the form below so that we can best serve your insurance needs.

Request Homeowner's Quote

Contact Information

Your Name:
State:          Zip:
Home Phone:
Work Phone:
Date of Birth:
Marital Status: Married   |  Single   |   Widowed   |   Divorced  

Information About Your Home
Ownership Type :
If Tenant, Contents Value:
Home Appraised Value:    
Year Built:         
Total Square Footage sq.ft.
Is There A Basement? Yes    |    No  
Is There A Deck? Yes    |    No  
Construction Type:
Deductible Amount: 
Closing Date:
Within City Limits? Yes    |    No  
Is this your Primary Residence?  Yes    |    No
Do you currently have coverage? Yes    |    No
If yes, who is current provider?
Current Policy Expiration Date:

Coverage Information

Personal Liability:

Medical Payments


Appraised Value

Appraised Value of Dwelling
Replacement Cost on Contents


Protection Devices (Check all that apply)

Smoke Detectors
Dead Bolt Locks
Fire Extinguisher
Non Smoker
Central Station Burglar Alarm (monitoring center)
Central Station Fire Alarm (monitoring station)
Police Station Direct Alarm (police station)
Fire Station Direct Alarm (fire station)
Local Burglar Alarm (premises only)
Local Fire Alarm (premises only)
Automatic Sprinkler

Additional Coverage

Scheduled Personal Property - Please enter amount of coverage you require for each:
Silverware:   Personal Jewlry:    
Camera:  Jewelry in Vaults:   
Musical Instrument: Guns:                     
Personal Furs: Golf Equipment:     
Comments: Please provide details for any claims submitted in the last 3 years, including the date of loss, type of loss and the amount paid.

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All Rights Reserved.