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Primary Insured's Occupation:
Date of Birth
MM slash DD slash YYYY
Dwelling Information
Year Home Built:
Home Square footage:
Is this Builder's Risk? (new home constr.)
Is this Builder's Risk? (new home constr.)
Yes
No
Month/Year home to be complete:
Number of units:
Type foundation:
Basement
Slab
Crawlspace over slab
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What % is finished
Type Construction:
Frame
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Other (list in remarks)
Type Roof:
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Number of stories:
1
1.5
2
3
Do you own animals or pets?
Do you own animals or pets?
Yes
No
If yes, list type/for dogs, list breed:
Are You Near Brush Area?
# of feet to nearest fire hydrant:
# of miles to nearest fire station:
Does home have a garage?
Does home have a garage?
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Tell whether built in, detached/attached, and how many cars?
Currently Insured?
Currently Insured?
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No
Name of Carrier & how long insured?
Prior Claims?
Prior Claims?
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Plumbing type:
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Circuit Breakers/Fuses?
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# Fireplaces:
Special features (i.e., deck, air conditioning, alarm systems, pool, etc.)
Coverages
Dwelling Cov. $
Contents $
Liability Cov. $
Deductible $ ($250, $500, $1,000, etc.)
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