Dwelling fire
GENERAL INFORMATION
Note- Coverage can not be bound or altered by this submission
First name
*
Last name
*
Address
City
State
Zip
Daytime telephone number
Alternate telephone number
Estimated Credit Rating
Excellent
Very Good
Good
Questionable
Email address
*
PROPERTY TO BE INSURED
Street Location of the Property
City & State
Zip
Year Built
Construction
Frame
Masonry
Superior
Square Footage
Less Than 800
800 - 1000
1000 - 1200
1200 - 1500
1500 - 2000
2500 - 3000
3000 - 3500
3500 - 4000
4000 - 5000
More than 5000
Alarm Type
None
Local
Reporting
Central
Fire Hydrants
No
Yes
Roof
Peaked
Flat
Single Pitch
Oil Tank
None
Underground
In Basement
Above Ground
Swimming Pool
No
Yes Without Diving Brd
Yes With Diving Brd
Comments specific to this property
DESIRED COVERAGES
Dwelling Amount
Loss of Income
Deductible
100
250
500
Liability Limits
100,000
300,000
500,000
Effective Date
CURRENT POLICY INFORMATION
Renewal Date
Insurance Company
Describe any Losses in the Past 5 Years
COMMENTS
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