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Your "County" is?
Email
Phone
Fax
Primary Policyholder's Birthdate: (REQUIRED - Some companies products offer discounts for certain age groups.)
Dwelling Information
Year Home Built
Home Square Footage
Is this Builder's Risk? (new home constr.)
Yes
No
Month/Year home to be complete:
Number of units:
1 Family
Duplex
Type foundation
Basement
Slab
Crawlspace over slab
Other (list in remarks)
(If basement, what % is finished?)
% FINISHED
Type of Construction
Frame
Brick/Veneer
Stone
Other (list in remarks)
Type of Roof
Shingle
Wood Shake
Tar/Gravel
Spanish Tile
Metal
Other
Number of Stories
One
1.5
Two
Three
Do you own animals or pets?
Yes
No
If yes, list type/for dogs, list breed
Are You Near Bush Area?
Yes
No
# of feet to nearest fire hydrant
# of miles to nearest fire station:
Does Home Have a Garage?
Yes
No
Tell whether built in, detached/attached, and how many cars?
Currently Insured?
Yes
No
Name of Carrier & how long insured?
Prior Claims
Yes
No
Describe Claims in Detail
Rate Your Credit History and Past Insurance Payment History:
Excellent
Fair
Poor
Horrible
Plumbing Type
Copper
Galvanized
Mixed (Copper/Galvanized)
Heating Type
Gas (Propane or natural)
Electric
Electrical (if oil, list tank location in remarks) Circuit Breakers or fuses?
Breakers
Fuses
# Bedrooms
# Bathrooms
# Fireplaces
# Chimneys
Special Features
Coverages
Dwelling Cov. $
Contents $
Liability Coverage $
Deductible $ ($250, $500, $1,000, etc.)
Comments of Remarks
Describe any scheduled jewelry, in-home business, oil tank location, or other special coverages/remarks here:
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