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General Information
Name
*
Address
City
State
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Zip
Phone
Fax
Email
*
How did you hear about us?
Home Information
Type of home
*
Single Family Home
Duplex
Mobile Home
Manufactured / Modular Home
Please select your type of home.
Occupancy
Owner Occupied
Rented / Non-Owner Occupied
2nd Home
Seasonal
Vacant
# of Non-Relatives in Home
(Roommate, Fiance, Friend, Etc)
Renting a room to anyone?
Yes
No
Currently have a policy in place now?
Yes
No
Is the home in escrow?
Yes
No
Has the home been in foreclosure in the past 3 years?
Yes
No
Year built?
Square feet?
# of Stories?
Roof Type
Composition shingle
Tile
Gravel
Wood
Other
Foundation
Concrete Slab
Raised (crawl space) (0-100%
)
Garage
Attached
Detached
Built-in (room over garage)
Carport
# of cars the garage can hold:
Alarm?
Central
Local
None
Dogs in household?
Yes
No
Quantity
Breed(s)
Any unique features of the home?
Yes, list:
No
Gated community?
Yes
No
Trampoline on the premises?
Yes
No
Any claims in the last 3 years?
Yes. Describe briefly:
No
In home business?
Yes, please describe
No
If any foot traffic (people) to your home for business reasons, please list:
If any business equipment in home, please list:
Flat roof
Yes
No
Outdoor Pool/Jacuzzi?
Yes
No
Diving board or slide
Yes
No
100% Copper pipes
Yes
No
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