Agency Name: |
Phone:
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Agency Contact: |
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E-mail Address: |
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Applicant Name: |
Occupation:
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Applicant Phone: |
DOB:
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Location Address: |
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City: |
State:
Zip:
|
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New Purchase: |
Y
N
Prior Carrier:
Prior Premium:
|
Lapse in Coverage: |
Y
N
If Yes, Date Of Last Coverage:
|
If Lapse, Explain: |
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Occupancy: |
|
Number of Families |
|
Distance to Brush |
Distance to Fire Hydrant
|
Protection Class (1 - 10): |
Distance to Fire Department
|
Losses: |
Any losses in the Last Five (5) Years? Yes
No
|
If Yes, Explain: |
|
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Dwelling Amount: |
|
Extended Replacement Cost: |
125%
Yes
No
|
Roof Type: |
|
Deductible: |
|
Year Built: |
Sq Footage:
|
Home Updates: |
Roof:
Plumbing:
Electrical:
Heating:
|
Protective Devices: |
Burglar Alarm: None
Local
Central
| Smoke Detectors: Yes
No
|
|
Fire Alarm: None
Local
Central
| Interior Sprinklers: Yes
No
|
Personal Property: |
Replacement Cost Y
N
|
Personal Liability: |
|
Water Back Up: |
|
Personal Injury: |
Y
N
Identity Fraud Y
N
|
Gated Community: |
Yes
No
|
Animals? |
Yes
No
|
If yes, what kind: |
|
Wood Burning Stove: |
Yes
No
|
Earthquake: |
Yes
No
| EQ Deductible:
10%
15%
|
|
Notes |
|
|
|
|
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