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Insured Info

1. First Name(required)
2. Last Name(required)
3. Date of Birth(required)
4. Spouses First Name
5. Spouses Last Name
6. Spouses Date of Birth

Contact Info

1. EMail Address(valid email required)
2. Home Phone Number
3. Alternate Phone Number

Mailing Address

1. Street Address
2. City
3. State
4. ZIP

Insured Location

1. Township
2. Street Address
3. City
4. State
5. Zip

Home Info

1. Market Value
2. Dwelling Coverage
3. Liability Coverage $300,000 $500,000 $1,000,000
4. Year Built
5. Age of roof
6. Age of furnace
7. Age of water heater
8. Construction Frame w/ Wood Siding Frame w/ Vinyl Siding Frame w/ Aluminum Siding Frame w/ Brick/Stone/Stucco Fire Resistant
9. Pool? None Above Ground In Ground - No Slide or Diving Board In Ground - With Slide or Diving Board
10. Woodstove?
11. No Yes
12. Trampoline?
13. No Yes
14. Hydrant Distance
15. Less than 1000 ft More than 1000 ft
16. Fire Station Distance
17. Less than 5 mi More than 5 mi
18. Claims?Include details, dates, and paid amounts

 

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