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Policy Requested:
What coverage package do you wish?
Full Package
Fire and Liability
Liability only
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Are you interested in mortgage protection?
Yes
No
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Coverage Liability
25,000
50,000
100,000
250,000
500,000
1,000,000
5,000,000
10,000,000
Not sure
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Coverage Amount?
25,000
50,000
100,000
250,000
500,000
1,000,000
5,000,000
10,000,000
50,000,000
Not sure
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Deductible Value?
100
250
500
1000
2000
2500
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Personal:
What is your date of birth?
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What is your gender?
Male
Female
Other
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What is your occupation?
Employed
Government
Homemaker
Retired
Student living with Parents
Student not living with Parents
Unemployed
Military
Retail
Sales
Marketing
IT
Medical
Unknown
Business Owner
Student
Sales Inside
Sales Outside
Scientist
Other Technical
Military enlisted
Architect
Other
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What is your marital status?
Married
Divorced
Separated
Single
Widowed
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What is your education level?
Bachelors Degree
Master Degree
Doctorate Degree
High School Diploma
Some College
Associate Degree
Other
None
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What is your credit rating?
Excellent
Good
Fair
Bad
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What is your type of residence?
Own House
Renting
Student Housing
Other
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Years spent at residence?
0
1
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79
80
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Months spent at residence?
0
1
2
3
4
5
6
7
8
9
10
11
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What type of property is it?
Single Family
Apartment
Duplex
Condo
Townhouse
Mobile Home
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Are you the owner of the property?
Yes
No
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Are you living in the property?
Yes
No
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Property ZIP code
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Property address
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What is the municipal Lication?
Inside City Limits
Outside City Limits
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What is the type of occupancy?
Primary Residence
Seasonal Residence
Vacation
Rental
For sale
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Is the property newly purchased?
Yes
No
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What is the foundation status?
Basement fully furnished
Basement half furnished
Basement unfurnished
Crawl Space
Slab
Other
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What kind of garage?
Attached 1 Car
Attached 2 Cars
Attached 3 cars
Attached Carport
Detached 1 Car
Detached 2 Cars
Detached 3 Cars
Detached Carport
No Garage
Other
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How many bathrooms?
1
1.5
2
2.5
3
3.5
4
4+
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How many bedrooms?
1
2
3
4
5
5+
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Is Home Security available?
None
Monitored
Unmonitored
Unsure
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Is a Fire Alarm available?
None
Monitored
Unmonitored
Unsure
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What is the Story Level?
One Story
Bi Level
Two Stories
Trilevel
Other
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What type of roof?
Asphalt
Wood
Tile
Flat
Metal
Concrete
Slate
Composition
Other
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How old is the roof?
1-5
6-10
11+
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When was the property build?
2040
2039
2038
2037
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1803
1802
1801
1800
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When was it last upgraded?
2040
2039
2038
2037
2036
2035
2034
2033
2032
2031
2030
2029
2028
2027
2026
2025
2024
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1952
1951
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1948
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1945
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1941
1940
1939
1938
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1935
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1932
1931
1930
1929
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1926
1925
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1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
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Property Size in Square Foot
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What is the dwelling value?
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How would the construction class be categorized?
Standard
Luxury
Economical
Manufactured
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What is the Type of Construction?
Wood Frame
Metal Frame
Brick
Stucco
other
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What type of panel?
Circuit Breaker
Fuse Box
Other
Unknown
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Proximity water distance?
Not applicable
Within 1000 Feet
Within 1 Mile
Within 5 Miles
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What is the primary heating type?
Gas
Electric
Oil
Coal
Wood
Propane
Stove
Other
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What type of exterior walls?
Brick
Wood
Stone
Aluminum Siding
Vinyl Siding
Veneer
Cider Block
Stucco
Other
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What kind of wiring?
Copper
Aluminum
Knob and Tube
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Dog in house?
None
Doberman
German Shepherd
Pit Bull
Rottweiler
Other
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Features:
Deadbolts available?
No
Yes
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Fire extinguisher available?
No
Yes
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Is there a swimming pool?
No
Yes
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Is the swimming pool fenced?
No
Yes
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Is there a trampoline?
No
Yes
An error exists
Floodplain available?
No
Yes
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Covered deck or patio available?
No
Yes
An error exists
Is there a fireplace?
No
Yes
An error exists
Is there aire station within 5 miles?
No
Yes
An error exists
Is there a fire hydrant within 1000 feet?
No
Yes
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Indoor sprinklers installed?
No
Yes
An error exists
Copper water pipes installed?
No
Yes
An error exists
Brush hazard within 500 feet?
No
Yes
An error exists
Central air condition installed?
No
Yes
An error exists
Is there a sauna?
No
Yes
An error exists
Hot Tub available?
No
Yes
An error exists
Wood burning stove available?
No
Yes
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Is there a sump pump?
No
Yes
An error exists
Is there a smoker in household?
No
Yes
An error exists
Policy Current:
Are you currently insured?
No
Yes
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Current Insurance Company
Company not listed
21st Century
AAA
AARP
AIG
Access Insurance
AETNA
AFLAC
AIU
Alfa Insurance
All Risk
Allianz
Allied
Allstate
American Alliance Insurance
American Family
American Home Assurance
American Insurance
American International Insurance
American International Pacific
American Internacional south
AMS User Group
American International South
American Direct Business Insurance
American Deposit Insurance
American Casualty
American Manufacturers
American Empire Insurance
American Financial
American Health Underwriters
American Mayflower Insurance
American Motorists Insurance
American National
American Premier Insurance
American Protection Insurance
American Automobile Insurance
American Reliable
American Republic
American Savers Plan
American Service Insurance
American Skyline Insurance Company
American Spirit Insurance
American Standard Insurance
AmeriPlan
Ameriprise
Amica
Answer Financial
Anthem
Arbella
Armed Forces Insurance
Associated Indemnity
Assurant
Atlanta Casualty
Atlantic Indemnity
Atlantis
Auto Club Insurance Company
AXA Advisors
Auto Owners
Bankers Life and Casualty
Banner Life
Best Agency USA
Blue Cross / Blue Shield
Brooke Insurance
Commonwealth
Cal Farm Insurance
California State Automobile Association
Chubb
Cigna
Citizens
Clarendon
Clarendon National Insurance
CNA
Colonial Insurance
Comparison Market
Continental Insurance
Cotton States
Country Insurance and Financial Services
County Insurance and Financial Services
Countrywide
Countywide
CSE Insurance Group
Dairyland Insurance
eFinancial
eHealth Insurance Sercies
eHealthInsurance Services
Electric Insurance
Elephant
Equitable Life & Casualty Insurance
Erie Insurance
Esurance
Farm Bureau/Farm Family/Rural
Farmers
FinanceBox.com
Fire and Casualty Insurance Co of CT
Farmers Union
Fidelity Insurance Company
Fidelity National
Fireman’s Fund
Foremost
Foresters
Geico
AMSUserGroup
Garden State Life Insurance Company
GMAC
Golden Rule Insurance
Government Employees Insurance
Government Empoyees Insurance
Grange
Great American
Great West
Guaranty National Insurance
Guide One Insurance
Hanover Lloyd’s Insurance Company
The Hartford
Guardian
Guideone
Hartford AARP
Health Benefits Direct
Health Care Solutions
Health Choice One
Health Net
Health Plus of AmericaHealthMarkets
HealthShare American
Horace Mann
Horace Mann Insurance
Humana
IFA Auto Insurance
IGF Insurance
IDS
IHIAA
Infinity Insurance
Insurance Insight
Infinity National Insurance
Infinity Select Insurance
Insphere Insurance Solutions
Insurance Shopper, Inc
Insurance.com
Integon
Iroquois Group
John Hancock
Kaiser Permanente
Kemper Lloyds Insurance
Landmark American Insurance
Leader Insurance
Leader Preferred Insurance
Leader Specialty Insurance
Liberty Insurance Corp
Liberty Mutual
Liberty National
Liberty Northwest
Liberty Nothwest
Lincoln Benefit Life
Lumbermens Mutual
Maryland Casualty
Mass Mutual
Mega/Midwest
Matrix Direct
Mercury
MetLife Auto and Home
Metropolitan Insurance Co.
Mid Century Insurance
Continent Casualty
Middlesex Insurance
Midland National Life
Mutual Insurance
National Insurance
Miller Mutual
Modern Woodmen of America
Mutual of New York
Mutual Of Omaha
National Ben Franklin Insurance
National Casualty
Continental Casualty
Continental Divide Insurance
National Continental Insurance
National Fire Insurance
National Health Insurance
National Indemnity
National Union Fire Insurance
Nationwide
New England Financial
New York Life Insurance
Northwestern Mutual Life
Nortwestern Mutual Life
Norhwestern Pacific Indemnity
Northwestern Pacific Indemnity
Omni Insurance
Orion Insurance
Pacific Insurance
Pafco General Insurance
Patriot General Insurance
Peak Property and Casualty Insurance
PEMCO Insurance
Physicians
Penn Mutual
Pennsylvania life
Premier
Primerica
Principal Financial
Progressive
Protective Life
Prudential Insurance Co.
RBC Liberty
Reliance Insurance
Republic Indemnity
Response Insurance
SAFECO
Safeway Insurance
Security Insurance
Senior Market Sales
Sentinel Insurance
Sentry
Shelter
St. Paul Insurance
Standard File Insurance Company
Standard Fire Insurance Company
State and County Mutual Fire Insurance
State Farm
State National
Superior American Insurance
Superior Guaranty Insurance
Superior Insurance
Sure Health Plans
The Ahbe Group
The General
TICO Insurance
TICO Insurance1
TIG Countrywide Insurance
Titan
TransAmerica
Travelers
State Consumer Insurance
Twin City Fire Insurance
UniCare
United Insurance
United American/Farm and Ranch
United Life Group
United Pacific Insurance
United Security
United Services Automobile Association
Unitrin Direct
Universal Underwriters Insurance
US Financial
US Health Group
USA Benefits / Continental General
USA Benefits/Continental General
USAA
USF and G
Viking Insurance
Western and Southern Life
Western Mutual
William Penn
Windsor Insurance
Woodlands Financial Group
Zurich North America
Other
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Current coverage package?
Full Package
Fire and Liability
Liability only
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Insurance end
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Insured since
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Claims:
Do you have Claims or Losses in the past 5 years?
No
Yes
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Type of Claim
Fire
Hail
Liability
Medical
Theft
Water
Wind
Vandalism
Other
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Date of Claim
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Amount Paid in USD
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*Last Name
*Phone number
*Email
*ZIP
*Street Address
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