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HOME OWNERS INSURANCE QUOTE
REQUEST
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Personal Information |
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What is your name? |
Last
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First
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Middle
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What is your mailing address? |
Street
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City
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State
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Zip
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What is your telephone number? |
Home
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Work
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| What is your fax number? |
Fax
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| What is your email
address? |
Email
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What is your date of birth
(for discount purposes)? |
Date of Birth
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Property Information |
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What is the property address? |
Street
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City
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State
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Zip
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| What is the market value
of your home? |
Market Value
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| Number of families? |
#Families
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| What is the dwelling type? |
Dwelling Type
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| How many bathrooms are
there? |
Number of Full Bathrooms
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Number of Half Bathrooms
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| How many fireplaces are
there? |
Number of Fireplaces
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| How many porches or decks
are there? |
Porches or Decks
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Square Footage of Porch/Deck
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| What year was it built? |
Year Built
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| What date was the property
purchased? |
Purchase Date
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| What is the construction
type? |
Construction Type
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How many
stories? |
Stories
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| What is the total square
footage of the building? |
Total Square Footage
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| What foundation type? |
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| What type of garage? |
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| What type roof covering? |
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| Was the roof updated? |
Updated Roof
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Yes No |
| If yes, what year? |
Year Roof Updated
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| Does the building have a
pool? |
Pool
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Yes
No
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| If there is a pool, is it
fenced? |
Pool Fence
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Yes No
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| If there is a pool, is
there a lockable fence? |
Lockable Fence
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Yes
No |
| If there is a pool, is
there a diving board? |
Pool Diving Board
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Yes
No
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| If there is a pool, is
there a slide? |
Pool Slide
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Yes No
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| What is the distance of
fire protection? |
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| Is there a smoke alarm? |
Smoke Alarm
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Yes No
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| Is there a fire
extinguisher? |
Fire Extinguisher
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Yes No
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| Are there deadbolts? |
Deadbolts
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Yes No
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| Is the electrical updated? |
Electrical Update
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| Are there circuit
breakers? |
Circuit Breakers
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Yes
No
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| Does the electrical
circuit box have copper wiring? |
Copper Wiring
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Yes No
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| Do you have central air? |
Central Air
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Yes No
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| How old is the heating/
air conditioning? |
Age Heating/ Air Conditioning
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| Is the heating/ air
conditioning thermostatically controlled? |
Thermostatically Controlled
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Yes
No |
| What is the energy source? |
Energy Source
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| What is the heating
system? |
Heating System
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| What is the cooling
system? |
Cooling System
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| Has the plumbing been
updated? |
Plumbing Updated
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Yes
No |
| Does the building have
interior automatic fire sprinklers? |
Automatic Fire Sprinklers
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Yes
No |
| Is there a theft alarm? |
Theft Alarm
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Yes No |
| Is there a fire alarm? |
Fire Alarm
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Yes No |
| Are the alarms Monitored? |
Monitored Alarms
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Yes No
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| What is the fire district? |
Fire District
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| Do you have a trampoline? |
Trampoline
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Yes No |
| Number of acres dwelling
is located on |
Number of acres
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| Are there dogs on the
property? |
Dogs on Property
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Yes No |
| If yes, how many and what
is the breed of each dog? |
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| Are there any other pets
or animals on the property? |
Pets or Animals
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Yes
No |
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If yes, how
many and what is the description of each? |
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Current Coverage Information |
| What is the current
insurance company? |
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| What is the expiration
date of current policy? |
Expiration Date
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| Where there any losses or
claims in the last 5 years? |
Losses - Claims
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Yes No |
| If yes, what is the date,
amount paid and description of each loss or claim? |
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Desired Coverage Information |
| Dwelling Amount
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Coverage A
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Other
Structures |
Coverage B
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| Personal Property |
Coverage C
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| Loss of Use |
Coverage D
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| Premise Liability |
Coverage E
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| Policy Deductible |
Amount
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| Do you want building
replacement cost coverage? |
Yes
No |
| Do you want contents
replacement cost coverage? |
Yes
No |
| Questions or Comments |
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