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Name:
Address1:
Address2:
City:
State:
Zip Code:
Home Phone:
Alt Phone:
Email:
Number of Years at Current Residence:
Prior Address (if less than 3 years):
Dates of Birth His: Hers:
Occupation His: Hers:
Employer His: Hers:
Inside City Limits?
Distance from Fire Hydrant:
Name of Responding Fire Dept:
Distance from Fire Dept to your Home:
INFORMATION CONCERNING YOUR HOME
(Information can be obtained through the Tax Office or your Realtor)
Year Built:
Square Feet:
How Many Stories:
Type of Construction:
If home is over 25 years old, have updates been made to:Heating Wiring Plumbing
Type of Roof:
Age of Roof:
Central Heat:
Swimming Pool:
Gararge Type:
Number of Cars:
Square Feet:
Porches:
Open Porches Square Feet:
Enclosed Porches Square Feet:
INFORMATION CONCERNING YOUR COVERAGES
Dwelling Amount:
Contents Amount:
Liability Limits:
Medical Payments:
Deductible 1:
(Ex: Hurricane, Wind, Storm, Hail)
Deductible2:
(Ex: Water, Fire, Lightening, Theft, Vandalism)
Optional Coverages
Scheduled Personal Property Total Amt:
Jewelry:
Cameras:
Furs:
Silverware:
Fine Arts:
Coins:
Stamp Collection:
Do you own other Jewelry, Watches, and/or Furs valued over $500?
Increased Limit on Jewelry, Watches, Furs (HO-110)
Residence Glass (HO-105):
Personal Injury (HO-201):
Do you own other real estate property?
If yes, Do you occupy this property?
Do you lease the property out?
Rental Property (HO-225):
Locations:
Do you own any land?
If yes, How many acres?
ADDITIONAL INFORMATION
Do you have a Central Alarm System?
Dead Bolt Locks?
Smoke Detectors?
Fire Extinguishers
Describe any Claims during the past 3 years:
My Current Homeowners Carrier is:
My Current Homeowners Policy expires:
Additional Information: