~ Access Insurance Group ~

Phone: 305-592-7700
Fax: 305-593-8785

Main Office:
8726 NW 26 St. #11
Doral, FL 33172

Please complete the following form and you will be contacted by one of our Customer Service Representatives with a quote:

*Required Fields
*Name on Title
*Property Address
*City
*State
*Zip
*Phone
*Email

ADDITIONAL INFORMATION
New Purchase?	Yes No
If No, Please Complete the Following 3 Questions:
Prior Insurance Company
Effective Date
Expiration Date

Purchase Price
Year Built
Square Feet
Bedrooms
Bathrooms
Number of Stories
What type of roof do you have?
Do You Have a Pool?	Yes No
If Yes, Is It Fenced or Screened In?	Fenced Screened Neither
Do You Have a Porch?	Yes No
If Yes, Is It Open or Screened In?	Open Screened
Do you have a carport or garage?	Carport Garage Neither
What type of Air Conditioning?	Central Wall Units

Type of House	Single Family Townhouse Twin Home Condo
Is the house occupied?	Yes No
If yes, who is the occupant?	Owner Tenant
Is the home in a flood zone?	Yes No

The information you will submit will be stored securely and will not be sold or given to any third party except where required to do so by law. Submission of this form constitutes your consent for a representative of Access Insurance Group to contact you even if your phone is on the National Do Not Call List.