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Your
Name:

Email
Address:

Address &
Zip Code:

Phone
Number:

Provide us with the following information for your customized quote

mm

dd

Expiration date of your current policy

Current Insurance Company:

Zip Code:

Address of Property to be Insured:

Anyone smoke?

Yes

No

Mortgage Amount:

If no, how long at this address:

Are you a first-time homebuyer?

Yes

No

Have you reported any property claims within the past 3 years?

If yes, please give
claim details here:

Yes

No

Number of Units

Building

Garage

Roof Type

Year Built

Square Feet

Safety Features
complete each question

Is the home equipped with at least one working smoke alarm?

Yes

No

Do all exterior doors have dead-bolt type locks?

Yes

No

Does your home  have at least one fire extinguisher 2 1/2 pound or larger?

Yes

No

Yes

No

Is there a central station monitored burglar alarm system?

Exterior Walls
enter percent of each as it applies to your home
(total must equal 100%)

Stucco on Frame

Wood Siding

Brick Veneer

Aluminum Siding

Stucco on Masonry

Stone Veneer

Wood Shakes

Paint on Masonry

Solid Brick

Home Enhancements
check the box if your home has any of the following items

Burglar Alarm

Central Vacuum

Intercom System

Stained Glass

Fireplace

Trash Compactor

Electric Air Cleaner

Air Conditioner

Swimming Pool

Solar Panels

Sauna

Other Home
Enhancements
list the quantity of each

Number of
Bathrooms

Garage Door Opener

Jacuzzi/Hot-tub

Skylights

Wet bar

Cooling and Heating
check all that apply

Forced Air Conditioning and Heating

Swamp Cooler

Wall Heater with thermostat

Wood Stove

Wall Heater without thermostat

Deductible

Replacement Cost
of your Contents

Replacement Cost
of your Home

Home Warranty

Mortgage
Protection

Additional Coverage Request or Questions