Full Name:          
Address to be Insured:
Zip Code:
Email Address: (Required) 
Home Phone:   Work Phone:   Ext.
How to Contact You:       Cell Phone:
Date of Birth:              (mm/dd/yyyy)
Social Security #:       

Spouse Name:             
Date of Birth:              (mm/dd/yyyy)
Social Security #:       

Do you currently have Florida Flood Insurance?
Do you currently have FL Homeowners Insurance?
Coverage requested for?
Usage Type:
Years Lived at Address to be Insured:  

Florida Homeowners Insurance Coverages & Limits of Liability:

Dwelling ($ value):
Additional Structures ($ value):
Personal Property ($ value):    

Personal Liability (each occurence):
Medical Payments (each person):   
Other Perils Deductible:
Windstorm Deductible:

Policy Endorsements:

Replacement Cost, Dwelling: Yes No
Replacement Cost, Contents: Yes No

Florida Homeowners Insurance - Dwelling Information:

Building Structure:
Year Dwelling Built:     Dwelling Square Feet:
Smoke Detectors?             Deadbolt Locks?    
Central Burglar Alarm?      Central Fire Alarm?
Sprinklered All Rooms?
Primary Heat Type:
Do you have a Wood Stove? If yes, is it on a separate flue?

Full Baths:     Half Baths:   
Garage:         Garage Size:

Type of Wiring:         
Wiring Renovation:         Wiring Renovation Year:   
Plumbing Renovation:     Plumbing Renovation Year:
Heating Renovation:       Heating Renovation Year:  
Roofing Renovation:       Roofing Renovation Year:  
Roof Type:     Roof Age (years):
Exterior Paint Renovation:     Exterior Paint Renovation Year:

Dwelling Distance from Fire Department:  miles
Dwelling Occupied By:
Swimming Pool:              Diving Board:  
Pool Screened:               Approved Fence:  

Loss History:

Did you have any losses, whether or not paid by insurance, during
the last 3 years, at this dwelling location or any other location?
If the answer to the previous question was "Yes", please explain below.

Date                            Type                      Description of Loss           Loss Amount

Additional Information or Comments

Click on the "Submit Quote Request" button below to send
your Florida Homeowners Insurance quote request.**

**Information received from this Florida Homeowners Insurance quote request
form sent to Optimal Insurance Group will be for our use only and will not be sold,
given to or distributed to any other parties. A quote will be based on the Florida
homeowners insurance policy information provided and does not guarantee
acceptance of the risk by us. The precise coverage afforded is subject to
meeting underwriting guidelines, and the terms, conditions and exclusions of
the policy as issued. By submitting this request you acknowledge that this is
neither an offer to insure nor a guarantee of insurance. Completion of this
form does not entitle you to a Florida Homeowners Insurance policy. We are
licensed in Florida and will not provide homeowners quotes for other states.

Insurance Quote
Optimal Insurance Group
of Boca Raton, FL offers
affordable and
experienced personal
insurance coverage
services throughout south
Contact us about
Florida Health, Auto,
Renters, Homeowners,
Boat, Motorcycle, RV,
and Flood Insurance at
(561) 342-1695.
In addition to low cost
Florida Homeowners
Insurance quotes, we
also offer affordable
Health Insurance policy
premium quotes.
We are an independent Boca Raton, Florida insurance agency offering
affordable homeowners insurance policy premium quotes in the following
towns, cities and counties in south Florida: Boynton Beach, Gulf Stream,
Delray Beach, Lantana, Rainbow Lakes, Atlantis, Lake Worth, South Palm
Beach, Palm Springs, Greenacres, Wellington, Haverhill, Palm Beach,
Golden Lakes, Riviera Beach, Glen Ridge, West Palm Beach, Lake Park,
Royal Palm Beach, Jupiter, Coral Springs, Fort Lauderdale, Parkland,
Coconut Creek, Margate, North Lauderdale, Lighthouse Point, Hillsboro
Beach, Deerfield Beach, The Hamptons, Highland Beach, Weston,
Plantation, Playland Isles, Melrose Park, Lauderhill, Sunrise, Tamarac,
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Park, Opa Locka, Bunche Park, Hialeah Gardens, Palm Springs North,
Carol City, Norland, Ojus, Miami Lakes, Biscayne Gardens, Hallandale,
Sunny Isles Beach, Golden Beach, Aventura, Uleta, Miramar, Pembroke
Pines, North Miami Beach, Hallandale Beach, Ives Estates, Pembroke
Park, Coral Gables, Kendall, Dania Beach, Cooper City, Davie, West
Miami, Hollywood, Broward County, Martin County, Miami-Dade County,
and Palm Beach County, FL. We can also offer Florida homeowners
insurance coverage quotes throughout the Sunshine state, including in
Winter Haven, Lakeland, Miami, Orlando, Tampa, St. Petersburg,
Tallahassee, and Jacksonville, FL.
We can provide lower cost Florida Homeowners Insurance
coverage in the Palm Beach County, Florida area!
Applicant Information
Your Florida Homeowners
Insurance Quote Source
Optimal Insurance Group
4800 North Federal Hwy
Suite D-100
Boca Raton, Florida 33431
Palm Beach County FL
(561) 342-1695
Fax: 866-314-4026
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Florida Since 2002!
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