| Please fill in all the fields marked by a *, and then click the submit button when finished. |
| General Information |
| Name*: | |
| Address*: | |
| City*: | |
| ZIP Code*: | |
| State*: | |
| Phone*: | |
| Fax: | |
| E-mail Address: | |
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| House Description |
| Construction Type*: | Brick Frame |
| Year Built*: | |
| Please advise the date the following items have been updated if your house is over 20 years old: |
| Plumbing: | |
| Heating: | |
| Electrical: | |
| Roof: | |
| Is your home within 3 miles from a fire station?* | Yes: No: |
| Is your home within 500 feet of a fire hydrant?* | Yes: No: |
| Do you have smoke detectors?* | Yes: No: |
| Do you have fire extinguishers?* | Yes: No: |
| Do you want replacement cost coverage on your contents?* | Yes: No: |
| Are you a non-smoker?* | Yes: No: |
| If you own autos, would you be interested in combining the autos with the homeowners policy for additional discounts? | Yes: No: |
| Are you over fifty years of age? | Yes: No: |
| Do you own a dog?* If yes, please list breed: | Yes: No: |
| (Some of our companies have restrictions on the breeds of dogs they will write. Common breed restrictions include: German Shepherds, Rottweilers, Pit Bulls, Dobermans, Airedales and mixes with these breeds) |
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| Coverage Limits | |
| Dwelling*: | |
| Contents*: | |
| Liability*: | |
| Deductible*: | $250 $500 |
| List any items that you wish to have scheduled for a desired amount (jewelry, furs, etc) |
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| If you have had any homeowner claims or losses within the past 3 years, please explain: |
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| Do you have a pool?* | Yes: No: |
| Current Policy Expiration Date*: | |
| Any additional comments: |
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