| First Name: |
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| Last Name: |
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| Phone Number: |
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| Fax Number: |
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| E-Mail Address: |
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| Birthdate |
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| Who Referred You to Our Site?
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PROPERTY INFORMATION |
Property Address: |
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| Property City: |
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| Property State: |
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| Property Zip Code: |
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| Dwelling Type: |
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| Number Of Bedrooms: |
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| Number Of Bathrooms: |
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| Number of Fireplaces: |
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| Garage Description: |
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| Year Built: |
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| How Many Stories: |
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| If Two Stories, Ground Floor Square Footage: |
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| Total Square Footage of Your Dwelling: |
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| Construction Type: |
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| Roof Type: |
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| Roof Updated: |
yes
no
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| If Yes, Year Roof was Updated: |
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| Does The Dwelling Have A Pool? |
yes
no
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| If Pool, Is It Fenced? |
yes
no
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| If Pool, Is There A Diving Board? |
yes
no
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| If Pool, Is There A Slide? |
yes
no
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| Property Topography: |
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| Foundation Type: |
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| Protection Distance: |
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| Is Dwelling in the Brush? |
yes
no
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| Is there a Brush Hazard within (1) mile of Your Dwelling: |
yes
no
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| If yes, has the Brush been cleared by 250 feet from all sides of
Your Dwelling? |
yes
no
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| Losses-Claims in the last 5 years: |
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| If Yes, Date, Amount Paid & Description of Each Loss-Claim
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Questions or Comments
to help the Agent: |
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