Homeowners & Renters Information: |
Homeowner's or Renter's Full Name:
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Physical Address (P.O. Boxes Not Accepted):
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City:
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State:
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Zip Code:
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Phone Number:
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Email Address:
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Social Security Number (Your Privacy is Protected):
[to get you the best rate] |
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Date of Birth:
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Gender:
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Marital Status:
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Highest Completed Education:
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Occupation:
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Dwelling Type:
Single-Family
Townhome
Condo
Apartment
Other:
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Policy Type:
Homeowners
Renters
Landlords
Condo
Dwelling Coverage Amount:
Personal Property Coverage Amount:
Personal Liability Coverage Amount:
Water Back Up Coverage Amount:
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Year Built:
Purchase Date:
Purchase Price:
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Number of Units in Complex if Townhome, Condo or Apartment:
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Number of Stories (Homeowners and Renters):
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Dwelling Type (Ranch, Colonial, Contemporary, Etc.):
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Exterior Wall Construction Type (Frame, Masonry, Steel, Etc.):
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Siding Type (Aluminum, Cedar, Shake, Etc.):
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Roofing Type (Tar, Shingle, Metal, Etc.):
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Fireplace:
Yes
No
Single-Sided
Double-Sided
1 Fireplace
2 Fireplaces
3 Fireplaces
4+ Fireplaces |
Wood Burning Stove:
Yes
No |
Number of Rooms:
Bedrooms
Full Bathrooms
Half Bathrooms
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Foundation/Basement:
Slab
Piers
Unfinished
Partially Finished
Fully Finished |
Garage:
Yes
No
Attached
Detatched
Carport
1 Car
2 Car
3 Car
4+ Car |
Covered Patio/Deck:
Yes
No |
Swimming Pool:
Yes
No |
Trampoline:
Yes
No |
Tennis Court:
Yes
No |
TOTAL Square Footage (of Home or Building):
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Square Footage Your Unit Occupies (If Applicable):
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Vacancy Percentage (If Multiple Residence Building):
%
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Date That The Electrical, Heating, Plumbing & Roofing Was Updated (If Applicable):
Electrical
Heating
Plumbing
Roofing
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Wiring Type:
Copper
Knob & Tube |
Service Panel Circuit Breakers:
Yes
No |
Heating Type:
Central Gas
Baseboard
Radiant (Electric)
Radiant (Water)
Oil w/Tank
Propane w/ Tank |
Central Air Conditioning:
Yes
No |
Safety (Check if You Have):
Burglar
Fire
Smoke
Deadbolt
Fire Extinguisher
If you checked any of the above for Buglar, Fire and/or Alarm, are they professionally monitored?
Yes
No |
Is There A Fire Sprinkler System:
Yes
No |
Distance to Fire Hydrant (Feet or Miles):
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Distance to Fire Station (Feet or Miles):
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Distance to Coastal Waters (Feet or Miles):
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Pets:
Yes
No
Breed
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Jewelry or Other Scheduled Items:
$
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Is There A Business On Site:
Yes
No
Business Type
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Mortgagee (Bank) and/or Additional Interest:
Yes
No
Mortgagee Name
Address
Loan Number
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Additional Information: |
Additional Comments:
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Please let us know how you found us:
Google
Bing
Yahoo!
Other:
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