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Difficult to Place Homeowner Quote

Agency Name: Phone:
Agency Contact:
E-mail Address:
Applicant Name: Occupation:
Applicant Phone: DOB:
Location Address:
City: State: Zip:

New Purchase: Y N Prior Carrier: Prior Premium:
Lapse in Coverage: Y N If Yes, Date Of Last Coverage:
If Lapse, Explain:
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:

Dwelling Amount:
Extended Replacement Cost: 125% Yes No
Roof Type:
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%