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Residential Quote
PERSONAL INFORMATION
First Name
*
Last Name
*
Date of Birth
*
Co-Applicant First Name
Last Name
Date of Birth
Street Address
*
If current address is less than three years, please provide previous address
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
Phone Number
*
Email Address
*
Requested Agent
*
-
Brad Ray (Managing Partner)
Todd Hollowell (Agent)
Laura Ray (Partner)
David Bohmeier (Agent)
Traci Garcia (Client Services Manager)
CURRENT INSURANCE INFORMATION
Current Insurer (not agency)
*
Policy Expiration Date
*
Current Premium
*
PROPERTY INFORMATION
Policy Type
*
Homeowners
Condominium
Rental Property
Year Purchased
*
Year Built
*
Square Footage (not including basement)
*
Foundation Type
*
Slab
Crawl Space
Basement
Partial Basement
If basement, percent finished
100%
75%
50%
25%
0%
Number of Stories
*
Exterior Building Material (Majority)
*
Brick
Stucco
Wood Siding
Composite Siding
Vinyl Siding
Metal Siding
Log
Cedar
N/A Condo
Has the roof been replaced?
*
Unknown
Yes
No
N/A Condo
If yes, please provide year replaced
Any Pets
*
Yes
No
If yes, type and breed
COVERAGE INFORMATION
Dwelling Coverage Amount
*
Policy Deductible
*
1/2 % of Dwelling Value
1% of Dwelling Value
1000
1500
2000
2500
5000
10000
Policy Personal Liability Limit
*
100,000
300,000
500,000
1,000,000
Earthquake Coverage
*
Yes
No
Back up of Sewer/Drain Coverage (Basement Coverage)
*
Yes
No
If yes, amount requested
$5,000
$10,000
$15,000
$20,000
$25,000
$50,000
$100,000
Scheduled Items (Jewelry, Guns, Fine Arts etc.)
*
Yes
No
Type
Jewelry
Guns
Fine Arts
Furs
Total Coverage Amount
COVERAGE INFORMATION
Additional Comments
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