Name:
Address:
City:
State: Zip:
E-mail:
Phone:
Protection Class:
Construction:
Frame
Brick
Deductible:
$250
$500
$1000
Other
Age Of Home:
Dwelling Coverage (replacement cost of home):
Mature Homeowner Discount:
Age Of Husband:
Age Of Wife:
Within 1,000 Feet Of Fire Hydrant:
Yes
No
Distance From Fire Department:
Dept. Name:
Deadbolt Locks:
Yes
No
Smoke Detectors:
Yes
No
Fire Extinguisher:
Yes
No
Burglar Alarm:
Yes
No
(is it central station or reports directly to police & fire department)
Swimming Pool:
Yes
No
Fenced:
Yes
No
Bankruptcies (except medical bill documentation), judgements, foreclosures or repossessions within the last five years:
Yes
No
Claims For Damages To Your House Within The Last
Five Years:
Yes
No
Who Are You Currently Insured Through?
Renewal date of current homeowners policy
Any Items To Schedule Such As Jewelry, Fine Arts, Furs, Guns, Equipment, Etc.?
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