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Name
Address
City
State
ZIP
E-Mail
Phone Number
Best time to call
What do you own? Condominium Home Mobile home
Home comstructed of: Brick Frame Stucco Rock Log Home
What year was your home built?
Please list most recent updates in the plumbing, wiring, roof, and/or heater and the year they occured?
How much coverage do you currently have on your home/condo?
What is your deductible? $250 $500 $1000
What is the cuurent appraised value of your home/condo?
Do you have a wood-burning stove or fireplace insert? Yes No
Do you own a trampoline? Yes No
In the last three years, have you had any claims? Yes No
If yes, describe.
Do you have any unsatisfied Bankrupties, Judgments, Liens, Collections, Repossessions, Charge-offs, or Foreclosures? Yes No
Do you have Earthquake or Flood Insurance? Yes No
No, but I would like to learn more about it.
Do you have any high valued jewelry, guns, art, stamp, or coin collections? Yes No
Any additional comments or questions.