Brightway Insurance
The Bascelli Agency
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Home Insurance Quote
Protect your home with comprehensive coverage. Get a personalized quote tailored to your needs.
Referrer Information
Who Referred You To Us [Name and Company] We Want To Thank Them?
Owner 1 *
Tell us about the primary owner
First Name *
Middle Name
Last Name *
Email *
Phone Number *
Date of Birth *
Current Address (Where you have lived the most in the past 3 years) *
Check all that apply *
Retired
Current or Prior Military
Has a bankruptcy in the past 10 years
Ever been convicted of insurance fraud
Married
Single
Owner 2
Important to have this info to find the best rate
First Name
Middle Name
Last Name
Email
Phone Number
Date of Birth
Relationship to Owner 1
Select relationship
Check all that apply
Retired
Current or Prior Military
Has a bankruptcy in the past 10 years
Ever been convicted of insurance fraud
Married
Single
Questions on the Home You Want Quoted
Tell us about the property you want to insure
Address of the home you want quoted *
Is the home a new purchase or one you already own *
Select an option
What is the purpose of the home? *
Select purpose
Usage of the home *
Select usage
Type of home *
Select type
Age of Roof (put DK if you don't know) *
Age of air conditioning (put DK if you do not know)
Age of Hot Water Heater (put DK if you do not know)
Animals
Tell us about any animals on the property
Check ANY animals that will be on the property *
Dog
Horse
Chickens
Bees
Cows
Any other outdoor animal
None of these
Claims History
Information about prior insurance claims
List ANY Prior Home/Renters Insurance Claims in the Past 10 Years [What Happened] [ How much was paid] [When was it] *
Additional Interests
Are you interested in any other insurance products?
Are You Interested in ANY of the Following? *
Flood Insurance
Mortgage Protection Insurance
Liability Umbrella
Auto Insurance
Cycle / RV / ATV Insurance
Boat Insurance
I am not interested in any of these at this time
Additional Information
Any other info you want us to know
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