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Many of the companies we represent require this information prior to quoting.
Insurance
Have you had continuous coverage for at least 12 months?
Yes
No
If not, why not?
Present Insurance Co.
Present Coverage Amount
Renewal Date
Occupation
Claims in Last 5 Years
0
1
2
3
4+
Name Insured's and their Birthdates
List any Pets and their kind/breed
Deductable
250
500
1000
2500
Liability
300,000
500,000
1,000,000
Construction
Square Footage of Living Space
Year Home Was Built
Limit of Contents Coverage Needed
i.e. for apartments
Market Value
House Type
1-Story
1 1/2-Story
2-Story
Split Level
Bi-Level
Tri-Level
Quad-Level
Construction
Frame or Stucco
Masonry Veneer
Masonry
Vinyl
Aluminum
Foundation
Basement
Crawl Space
Slab
Roof
Asphalt Shingle
Wood Shingle
Tile or Slate
Age of Roof
Features
Garage
1-Car
2-Car
3-Car
4-Car
Attached
Detached
Basement
Built-In
Car Port
# of Full Bathrooms
1
2
3
4
5
# of Half Bathrooms
1
2
3
4
5
Other Features
Central Air Conditioning
Wet Bar
Security System
Central Vacuum
Whirlpool Tub
Pool
Credits
Smoke Alarm
Fire Extinguisher
Dead Bolt
Nonsmoker
Central Station
Premises
# of Fireplace Chimneys
1
2
3
4
5
# of Fireplace Hearths
1
2
3
4
5
Is Basement Finished?
Yes
No
Basement Sq. Ft
Deck Sq. Ft
Porch Sq. Ft
Screened Patio Sq. Ft
Enclosed Porch Sq. Ft
Comments
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