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Home Insurance
Quote (No Obligation) |
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Select the type of insurance
upon which you wish to receive a quote: |
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1. Name: |
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2. Date of Birth: |
(mm/dd/yyyy)
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3. Address (of property
to be insured): |
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4. City: |
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5. State: |
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6. Zip Code: |
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7. Phone: |
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8. Email: |
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9. What Year was the
property built? |
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10. Please estimate the
total square footage of the residence: |
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11. How many floors,
excluding the basement? |
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12. Number of baths: |
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13. Type of basement: |
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14. Is there a garage: |
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15. Type of garage: |
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16. Garage Size: |
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17. Total number of fireplaces: |
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18. Style of home: |
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19. Type of exterior: |
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20. Type of roof: |
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21. Select all that apply: |
Deadbolt Locks
Central A/C
Smoke Detectors
Fire Extinguisher
Swimming Pool
Central Alarm System |
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22. If protected by security
system, type: |
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23. Have you had any
claims in the last 5 years?: |
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Questions Regarding
Insurance Request |
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24. When you would like
your new policy to go into effect: |
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25. Requested Deductible: |
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26. Requested Liability
Coverage: |
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27. Do you own or rent?: |
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