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How did you hear about us?: *
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Owner #1, First & Last Name:
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Owner #2, First & Last Name:
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Street Address of Property:
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City:
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State:
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Zip code:
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Mailing Address:
Same as
property address
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Daytime Phone Number:
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Evening Phone Number:
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Email Address:
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Year Property was Built:
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Do you have current home owner's insurance?:
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Expiration date
(if you currently
have insurance):
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New home purchase?:
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Home Construction Type:
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Property Type:
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Dwelling Use:
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Indicate All Months Unoccupied
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January FebruaryMarch
April May June
July August Septmber
October November December
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Primary Heat Source:
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Number of Families:
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Number of Stories:
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Central Fire Alarm (must be monitored):
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Central Burglar Alarm (must be monitored):
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Electrical Updated:
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Year Electrical
Updated:
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Heating Updated:
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Year Heating
Updated:
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Roof Updated:
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Year Roof
Updated:
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PlumbingUpdated:
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Year Plumbing
Updated:
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Distance to Fire Hydrant (ft.):
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Inside City Limits:
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Amount of Coverage on Dwelling:
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Amount of Coverage on Personal Property:
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Personal Liability Coverage:
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Deductible:
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Hurricane Deductible:
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Medical Payments:
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(Note: Other coverage on the policy is based off a percentage of the total amount covered on the dwelling. Other Structures - 10% of dwelling, Loss of Use - 20% of dwelling. They can be greater percentages than listed, but not less.)
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Swimming pool or similar structure?
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If yes, is the
pool screened
or fenced?
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If yes, what is
the height of
the fence in feet?
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If yes, does
the pool having
a diving board or
slide?
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Is there a trampoline on property?:
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Is there a skateboard ramp on property?
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Do you have or intend to have any dogs on property?
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If yes, breed
kind of dogs?
If a mix,
what kind?
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Homes Over 20 Years Old:
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Are pipes copper?
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Age of water heater?
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Washing machine hoses replaced in the last 5 years?
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Any knob-tube wires in the house?
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Does the electrical system use fuses?
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Does home have 100 AMP or greater service?
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Do you currently have or have any plans for portable heating?
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Any poly-butylene pipes in the home?:
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Loss History: (List any losses within the last 5 years, type of loss, and amount)::
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Questions and Concerns about auto insurance?
Please list all of your questions and concerns, and an insurance professional will get in contact with you.
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