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| 1.Contact |
| NAME, ADDRESS AND CONTACT
INFORMATION |
| Fields marked (*) are
mandatory. |
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| First Name* |
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| Last Name* |
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| Home Phone* |
( ) - - |
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| Work Phone |
( ) - - Ext: |
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| E-mail* |
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| Reffered By |
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| SSN # |
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| Rate your credit |
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| 2. Property General |
| PRIOR INSURANCE |
| Fields marked (*) are
mandatory. |
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| Have prior insurance: |
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| If Other Insurer is selected Enter Insurer Name |
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| Have Insurance with them for* |
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| Estimated Yearly Premium (in US$) |
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| Prior Policy Ends On* |
YYYY |
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| 3.Property General |
| PROPERTY GENERAL |
| Fields marked (*) are
mandatory. |
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| Address 1* |
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| City* |
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| State* |
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| Zip Code* |
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| Property Surroundings* |
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| Distance to Fire Station* |
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| Distance to Hydrant(ft)* | Under 1000Over 1000 |
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| Year Built* |
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| Property Use* |
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| Square Footage* |
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| Number of Families* |
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| Number of Stories* |
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| Dog Type* |
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| 3.Property General |
| PROPERTY VALUES |
| Fields marked (*) are
mandatory. |
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| Purchase Date* |
YYYY
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| Purchase Price* |
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| Est. Current Market Value* |
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| Est. Replacement Value* |
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| 4.Property Details |
| CONSTRUCTION DETAILS |
| Fields marked (*) are
mandatory. |
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| Construction Type* |
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| Roofing Material* |
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| Age of Roof |
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| Electrical Type* |
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| Heat Type* |
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| Number of Fireplaces* |
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| Number of Bathrooms* |
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| 5.Property Details |
| PROTECTION DEVICES |
| Fields marked (*) are
mandatory. |
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| Burglar Alarm* |
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| Fire Alarm* |
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| Smoke Detectors* |
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| Fire Extinguishers on Each Floor | YesNoNot sure |
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| Fire Sprinkler System* |
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| 6.Property Details |
| BUILDING DETAILS |
| Fields marked (*) are
mandatory. |
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| Number of Basements* |
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| Basement Sq. Footage(est.) |
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| Basement Finished Percentage(est.) |
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| Garage Type* |
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| Garage Sq. Footage (est.) |
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| 7.Property Details |
| OTHER STRUCTURES |
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| Fields marked (*) are
mandatory. |
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| Swiming Pool Type* |
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| Swiming Pool Fence Construction Type |
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| Has Diving Board | YesNo |
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| 8.Application |
| ADDITIONAL
INFORMATION |
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| Fields marked (*) are mandatory. |
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| The questions bellow will help the Insurers to
determine the best discounts to be awarded |
| Have you had any reported losses during the past 3 years?* | YesNo |
| Any business conducted on premises? (including day/child care)* | YesNo |
| Any residence employees?* | YesNo |
| Has application had a foreclosure, repossession or bankruptcy during the past five years?* | YesNo |
| Does applicant own any recreational vehicles (snowmobiles, dune buggies, mini bikes, ATVs, etc.)?* | YesNo |
| Is building retrofitted for earthquake?* | YesNoNot sure |
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| 9.Coverages |
| BASIC COVERAGES |
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| Fields marked (*) are
Mandatory Coverages. |
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| COVERAGE NAME |
LIMITS
%BASE |
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| Dwelling* |
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| Other Structures* |
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| Personal Property* |
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| Loss of Use* |
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| Personal Liability* |
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| Medical payments* |
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| DEDUCTIBLES |
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| All Perils Deductible* |
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| CREDITS |
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| Non-Smoking Household | YesNo |
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