| Homeowner Insurance
Quote Form |
No homes built prior to 1960, no seasonal homes,
and no vacant exposures
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| Name: |
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| E-mail: |
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| Phone #: |
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| Location Address: |
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| City: |
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| State: |
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| Zip: |
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| Location and Mailing Same? |
Yes or No |
| If no from above, mailing address: |
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| City: |
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| State: |
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| Zip: |
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| DOB: |
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| SSN #: |
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| Year Built: |
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| Occupancy: |
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| construction: |
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| Prior Ins. Co.: |
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| Renewal Date: |
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| Force Placed Insurance: |
Yes or No |
| New Purchase: |
Yes or No |
| If new purchase, closing date: |
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| Roof Construction: |
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| # of stories: |
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| If over 1 story, construction of upper floors: |
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| # of baths: |
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| Size of Garage: |
cars |
| Fireplaces: |
Yes or No |
| Pool: |
Yes or No |
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In Ground or Above Ground |
| If there is a pool, slide?: |
Yes or No |
| If there is a pool, diving board?: |
Yes or No |
| Is the pool fenced?: |
Yes or No |
| Is the pool screened?: |
Yes or No |
| Any Dogs?: |
Yes or No |
| If yes to dogs, how many: |
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| If yes to dogs, breed: |
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| If yes to dogs, biting history?: |
Yes or No |
| Please list other structures (sheds, fences, detached garages, etc.): |
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| Does the home have: |
Sm Det.
Fire X
Deadbolts (All Doors)
C/S Fire
C/S Bur
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| Updates: |
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| Roof: |
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| Electric: |
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| Plumbing: |
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| Windows: |
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| Any Previous Claims? |
Yes or No |
| If yes to previous claims, please list: |
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| Previous Address: |
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