Please fill out the fields in the form below. One of our representatives will contact you within one business day to complete the process.

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Home Insurance

Personal Information

  • Effective Date Requested

    OKEffective Date Requested is required
  • OKName is required
  • Date of Birth

    OKDate of Birth is required
  • Social Security Number

    OKSocial Security Number is required
  • Home Phone

    OKHome Phone is required
  • Daytime Phone

    OptionalOKDaytime Phone is required
  • OKMailing Address is required
  • OKCity is required
  • OKState is required
  • OKZip is required
  • Use mailing address for residential address

    OKUse mailing address for residential address is required
  • OKResidential Address (if different than above) is required
  • OKCity is required
  • OKState is required
  • OKZip is required

Home Information

  • OKReplacement Cost Amount is required
  • OKYear Built is required
  • OKSquare Footage is required
  • OKStructure (Frame or Brick) is required
  • OKNumber of Stories is required
  • OKCrawl Space or Basement is required
  • OKAlternate Heat (Fireplace, Woodstove, etc.) is required
  • Central A/C

    OKCentral A/C is required
  • Occupancy

    OKOccupancy is required
  • OKPlease list any updates completed to home, including year completed is required
    OKLocated near tidal waters is required
  • OKMiles to nearest fire department is required
  • OKName of nearest fire department is required
  • OKFeet from nearest fire hydrant (If farther than 1000 feet, please input “1001”) is required
    OKSmoke Alarm in home is required
    OKDeadbolts on doors is required
    OKFire Extinguisher in Home is required
    OKCentral Burglar/Fire Alarm installed in home is required
    OKTrampoline, woodstove or pool on premises is required
  • OptionalOKIf pool, please list depth, whether fenced in, and if diving board is attached is required
  • OKAny Pets (If so, please list breed) is required
  • OKAny claims in the past 3 years (If so, please list) is required
  • OKPlease list scheduled item amounts for the following and describe (if applicable): Jewelry, Furs, Guns, Other is required
  • OKName of current company is required
  • OKYears with current company is required
  • OKPlease list current mortgagee (if applicable) is required
  • To provide you with an accurate quote, some of our carriers obtain information about you and other household members from consumer reporting agencies. This includes credit-based insurance score, claim histories and other consumer reports. They use this information to underwrite and rate your policy. They may order additional reports to update or renew your insurance. Each carrier has a Privacy Policy that explains how that company discloses and protects your information. A copy can be provided upon request.

Security Code

  • OK is required

    EVB reserves the right to use the above information to obtain verifications of identity and background before opening any accounts. We may also access information about you from a consumer reporting agency, such as a copy of your credit report, before opening any account. By submitting this form, you grant full permission to do so. Submission of this application does not guarantee that you will receive an offer of insurance and we may contact you if more information is required.