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PERSONAL INFORMATION
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Name:
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Property Address:
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City:
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State:
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Zip Code:
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Day Phone #:
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ext.
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Evening Phone #:
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ext.
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Cell Phone #:
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Email Address:
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Best time to call:
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Best way to reach you:
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How did you hear about us?:
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CURRENT INSURANCE POLICY INFORMATION
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Insurance company:
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Policy #:
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Policy expiration date:
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/
/
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Annual premium:
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$
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Are you being Non-Renewed or Cancelled?:
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If yes, reason for NR or Cancelled:
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"Coverage A - Dwelling Coverage" limit on policy:
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$
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All Other Perils ("AOP") deductible:
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Hurricane deductible:
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Occupancy:
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Dwelling use:
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Type of foundation:
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Type of dwelling:
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Year built:
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Living area square feet:
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Number of stories:
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Garage:
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Construction type:
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Roof type:
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Shape of roof:
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Age of roof:
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Years
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HOME UPDATES (if home is 25+ years old)
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Heating:
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If yes, year updated:
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Electrical:
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If yes, year updated:
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Plumbing:
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If yes, year updated:
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UNDERWRITING QUESTIONS
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Is the home currently for sale?:
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Is your home in a Flood Zone?:
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Is there a trampoline on the property?:
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Do you own an ATV or boat?:
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Filed any claims in the past 5 years:
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If yes, describe the claim:
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How much was paid?:
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$
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Age of Hot Water Heater:
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Years
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Age of Washing Machine Hose:
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Years
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Do you have a "monitored" alarm system?:
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Do you live in a gated community?:
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Do you have or intend to have any
dog(s) on the premises?:
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If yes, what breed is the dog(s)?:
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Do you have or intend to have any
non-domesticated animals on the premises?:
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If yes, what type are the animals?:
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Do you conduct any business on the property?:
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If yes, what type of business?:
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Do you have a swimming pool
or similar structure?:
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If yes, does the pool have a fence
and/or screened enclosure?
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Does the pool have a slide and/or diving board?:
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Have you and/or your spouse had a bankruptcy, lien,
foreclosure, or repossession in the past 5 years?:
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Have you and/or your spouse been convicted
of a felony in the past 10 years?:
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Have you and/or your spouse had your driver's
license suspended in the past 5 years?:
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Have you been involved in a lawsuit against an Auto or
Homeowner's insurance company in the past 5 years?:
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Have you been arrested for DUI, assault and battery
or disorderly conduct in the past 10 years?:
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