| GENERAL INFORMATION |
| Full Name |
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| Email Address |
required to submit form |
| Telephone |
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| Address |
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| City |
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| State |
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| ZIP Code |
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| Occupation |
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| Employer |
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| Do you have a spouse? |
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| CURRENT INSURANCE
INFORMATION |
| Insurance Carrier |
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| Expiration Date |
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| RATING INFORMATION |
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What year was the dwelling built? |
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What type of dwelling? |
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What type of construction? |
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What type of roof material? |
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How old is the roof? |
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Square Footage of dwelling |
square feet |
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Number of stories (floors) |
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Number of bedrooms |
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Number of bathrooms |
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| Garage type |
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Garage - Number of cars |
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Do you have? (check all that apply) |
Pool
Deck
Spa
Other outdoor buildings |
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Is the wiring upgraded? |
If yes, when?
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Is the plumbing upgraded? |
If yes, when?
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Has the dwelling been retrofitted for earthquakes? |
If yes, when?
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Do you have a wood stove? |
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Do you have a fireplace? |
If yes, what type?
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What is the primary source of heat? |
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What is the secondary source of heat? |
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Do you have a security system? |
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If yes, please describe: |
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Have you had any losses in the past 3 years? |
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If yes, please describe: |
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Do you own any pets? |
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If yes, please list all youru pets: |
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| SPECIAL COVERAGE NEEDS |
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Please add any information about special circumstances or coverage needs.
Include information about any Fine Arts, Jewelry, Coins, Guns, Safes, or
Other Collectibles. |
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Does your home have any "special features"? Please describe them. |
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