Jeffrey Acklie Insurance Agency

2210 N 91 Plaza
Omaha NE 68134-6022
402-391-1979 phone
402-397-6798 fax

Home Insurance Quote Request Page

The minimum requirements to receive your free home insurance quote is to want to insure a house within Nebraska and complete all items marked with a *.

The more information you supply, the more accurate the quote. All quotes are subject to verification of all underwriting factors.

Basic Address Information

Name*
Address*
City* Zip Code*

Please supply either a Daytime or Evening Phone Number
Also the best time to call.*
Home Phone Number:
Work Phone Number:
Best Time To Call Morning Afternoon Evening
E-mail Address:

Current Insurance Information

Policy Type Desired?
Homeowners Landlords Condominium Townhouse Renters
Current insurance carrier
(If you do not have a current insurance carrier type in NONE)
Policy Expiration Date/Premium Due Date
Amount of Insurance Desired
Dwelling Coverage (Amount of Insurance)
Separate Structures
Personal Property/Contents
Medical Payments
Personal Liability
(Bodily Injury and/or Property Damage)
Personal Injury Liability
(Slander,Discrimination,False Arrest,ect.)
Deductible
Number of Claims Filed Within the Past 5 Years
Please explain loss details, in the comments section below.

Additional Information/Comments

If you need any special endorsements (jewelry,guns,collectibles,furs,fine arts,ect.) or to clarify any items above: Please explain here.

Building Information

Year Built
Number of Stories.
Total Square Feet
Total Finished Square Feet
Construction Type
(Ranch, 2 story, Split entry, Tri-level, ect.)
What Type of Roof do you have?
(asphalt shingles, wood shakes, tar and gravel, tile, slate, ect.)
What is the Age of the Roof?
Garage Type/Size
Number of Bathrooms
Number of Fireplaces
Does your home have a Deck? Yes No
Do you have Monitored Central Burglar Alarm? Yes No
Does your house have,
Central Heating and Air Conditioning?		 Yes No
Do you have a Swimming Pool? Yes No
Is Flood Insurance Desired? Yes No
If you have any other special features in your home,
please explain in the comments section above.
Your request for a quote or the form

If you feel uncomfortable sending the above information over the net, please call my office at: 402-391-1979. I will gladly answer your questions. I look forward to helping you.

We welcome any additional information, which would help us develop our site futher please send it to us from here: jeff.acklie@farmersinsuranceagency.com

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