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PERSONAL INFORMATION |
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Name: |
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Property Address: |
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Lot #: |
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City: |
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State: |
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Zip Code: |
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Day Phone #: |
ext. |
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Evening Phone #: |
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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Annual premium: |
$ |
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Are you being Non-Renewed or Cancelled: |
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If yes, reason for NR or Cancellation: |
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"Coverage A - Dwelling Coverage" limit on policy: |
$ |
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All Other Perils ("AOP") deductible: |
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Hurricane deductible: |
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Property located in a park or subdivision: |
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If yes, name of park or subdivision: |
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Occupancy: |
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Dwelling use: |
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Year built: |
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Size of home: |
Width:
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Roof type: |
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If shingle roof, age of roof: |
Years |
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Carport:
Screen Room:
Enclosed Florida Room:
Shed:
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UNDERWRITING QUESTIONS |
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Are you a member of AARP: |
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Are you a member of AAA: |
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Is your home in a Flood zone: |
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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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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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