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Contact Information
Contact Name:
 
Property Address:
 
Property City:
 
Property State:
 
Zip Code:  
Primary Phone # to Reach You:
 
Alternate Phone # to Reach You:
 
Fax:
 
Email:  
Smoker:   Yes No
Current Age:  
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Your Apartment, Townhouse, Condo or Home Information
Number of Apartments in your building?  
Number of Stories:  
Roof Type:  
Construction Type:  
Living Area Square Feet:  
Year Built:  
Number of Bedrooms:  
Number of Bathrooms:  
Fireplace:  
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Security Options:    Smoke Detectors
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Dead Bolt Locks
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  Fire Extinguisher
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Automatic Fire Sprinklers
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Alarm System:  
   
Coverages
Desired Comprehensive Personal Liability?  
Desired deductible amount?  
Medical Payments to Others if hurt on your property?  
 
Questions
When do you need insurance by?   (mm/dd/yy)
How long have you lived at your present address?  
If you have coverage now, who is the Insurance Company?    
Current Insurance Premium?  
How long have you been with this company?  
Is your policy being Canceled or Non-Renewed?   Yes No
If you have had any reported claims in the last Five years, please briefly explain?  
To receive a larger discount would you consider also insuring your cars?   Yes No
Do you have any Questions or Suggestions?  

   
     
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