Name:
Address:	Street City                                                          State          Zip
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Home Phone:
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Current coverage:	Company:                                       Expiration Date:
Type of policy desired: Homeowners Insurance Renters Insurance Condominium Insurance
Amount of Insurance desired: Homeowners: What is the value of your home? Condominium and Renters: What is the value of your personal property? Liability Limit: $100,000 $300,000 $500,000 Medical Payments: $1000 $5000 Valuation of Home: Actual Cash Value Replacement Cost Personal Property Valuation: Actual Cash Value Replacement Cost Deductible: $250 $500 $1000
Property Information: What is the construction type of your home? Masonry Frame In what year was your home built? In what County are you located? Distance to the nearest fire hydrant? Less than 500 ft. Over 500, under 1000 ft. Over 1000 ft, under 3 miles Over 3 miles What kind of pets do you have? Do you have a swimming pool? Yes No Do you have a trampoline? Yes No Do you use a wood burner? Yes No Smoke Detector(s) Installed Home Security System Installed   Home Updates:  Enter year updates were made. If year not known, enter "unknown": Roof: Wiring: Plumbing: Heating:
Optional Property Coverages: Earthquake Coverage Requested Flood Coverage Requested Sewer/Water Backup Coverage Requested
Property Floaters - Indicate limits below: Antiques: Coins: Computers: Fine Arts: Furs: Jewelry: Stamps: Tools: Other Floater Coverage:     Limit of Insurance:
Previous Loss Information Please describe any losses or claims filed on your Homeowners Insurance in the last 3 years: Date of loss:               Type of loss:                                                Amount of claim:
Additional Comments Please use the box below to enter any additional information: