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name
property address
city
zip code
is mailing address different from address above? if yes,
mailing address
city:
zip code:
phone (optional)
e-mail address


property information

type of property    
any claim within 5 years  
if answer is yes,
type of loss
     
type of roof:      
any extra structure      

do you have any pets?

 

if pet is a dog:

how many?  
what type of breed  
any bite history?  
any type of formal training?  


any discount

burglar alarm:  
fire alarm:  
** proof required later **


property upgraded information

roof updated:   year
wiring updated:   year
heating updated:   year
plumbing updated:   year


coverage

liability:
medical:  
deductible:          


remarks

 


note: if you have any valuable art work  extensive amounts of jewelry, these items should be insured separately,  other items and collectables should also be insured separately, we will advise you of these items at a later date.


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