| Name: * |
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| Additional Names On Deed: |
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| Phone Number: * |
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| Mailing Address * |
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| Physical Address of Dwelling (If Different): |
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| E-mail Address: * |
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| Your Date Of Birth: * |
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| Do You Currently Have Home Insurance? * |
No Yes Newly Purchased Home |
| If You Currently Have Insurance, How Much Is It Insured For? Or, If This Is A New Purchase, How Much Did You Purchase It For? |
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| Have You Had Insurance Denied or Cancelled In The Last 3 Years? * |
No Yes |
| What Year Was The Home Built? * |
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| In What Year Did You Purchase It? * |
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| Is This A Seasonal Dwelling? * |
No Yes |
| Is This A Multi-Family Home? (Please Note That For A Homeowner Policy, It Must Be Owner-Occupied.) * |
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| Is This A Frame Or Masonary Building? * |
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| How Many Square Feet of Living Space? * |
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| How Many Stories Is House? * |
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| How Many Bedrooms? * |
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| How Many Full Bathrooms? * |
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| How Many 1/2 Bathrooms? * |
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| How Many Kitchens? * |
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| Is This House More Than 30 Years Old?(If No, Please Skip To Next Section) * |
No Yes |
| Has The Roof Been Replaced? |
No Yes |
| If Yes, What Year? |
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| Has The Furnace Been Replaced? |
No Yes |
| When Was The Furnace Last Replaced or Serviced? |
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| Are There Curcuit Breakers? |
No Yes |
| If No, Please Explain: |
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| What Kind Of Plumbing In House? |
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| What Type Of Siding Is On House? * |
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| What Type Of Shingles On Roof? * |
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| Is There A Basement? * |
No Yes |
| If Yes, Is It Full or Partial? |
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| If There Is A Basement, Is It Finished? |
No Yes Some Of It |
| What Percent Is Finished? |
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| Does The Basement Have A Walkout? |
No Yes |
| What Type Of Furnace Fuel Is Used? * |
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| If You Have A Tank For Fuel, Is It Underground? |
No Yes |
| Are There Any Woodstoves or Fireplaces? * |
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| Do You Have Central Air Or Air-Conditioning? * |
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| Do You Have Any Decks or Porches? * |
No Yes |
| If Yes, How Many, What Size(s), And What Are They Made Of? |
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| Is There An Attached Garage? * |
No Yes |
| If Yes, How Many Bay And What Size: |
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| Are There Any Outbuildings (Sheds, Unattached Garages, Barns, etc)? * |
No Yes |
| If Yes, How Many, What Size, And What Is It Used For? |
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| Do You Feel Your House Is: * |
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| If Certain Parts Are Custom, Please List: |
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| Do You Have Any Farm Animals? * |
No Yes |
| If Yes, Please List Types and Quanities: |
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| Do You Have Any Exotic Animals? * |
No Yes |
| If Yes, Please List Types and Quantities: |
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| Do You Have Any Dogs? * |
No Yes |
| If Yes, Please List Breeds: |
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| Are All Dogs On Premises Licensed? |
No Yes |
| Do Your Dogs Have Any History Of Biting? |
No Yes |
| If Yes, Please Explain: |
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| How Are The Dogs Restrained? |
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| Are There Any Swimming Pools On The Premises? * |
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| Is There A Fence Around The Pool? |
No Yes |
| How Many Feet Deep Is The Pool? |
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| Are There Any Trampolines? * |
No Yes |
| Is Any Business Conducted On Premises (Including Child Care)? * |
No Yes |
| If Yes, Please Explain: |
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| Do You Have A Generator? * |
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| Are There Working Smoke Alarms In The House? * |
No Yes |
| Do You Have A Home Security System? * |
No Yes |
| Who Is The Responding Fire Department? * |
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| Is The House Within 1,000 Feet Of A Fire Hydrant? * |
No Yes |
| Is The House Within 5 Miles Of A Fire Department? * |
No Yes |
| Do You Have Town Water or a Well? * |
Town Water Well |
| Do You Have A Submergible Pump (Sump pump)? * |
Yes No |
| Many Companies Offer Discounts If You Have Multiple Policies With Them. If You Have Any Other Insurance With Any Companies, Please Enter The Company And Type Of Policy Here: |
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| Some Of Our Companies Use Credit-Based Insurance Scoring, So Please Either Enter Your Social Security Number, Or Call Us With It, So That We May Provide You With An Accurate Quote. |
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| Please Enter Any Additional Information That You Think May Be Important, So That We May Get You An Accurate Quote: |
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| Verification: |
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