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Policy Requested:

What coverage package do you wish?
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Are you interested in mortgage protection?
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Coverage Liability
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Coverage Amount?
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Deductible Value?
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Personal:

What is your date of birth?
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What is your gender?
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What is your occupation?
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What is your marital status?
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What is your education level?
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What is your credit rating?
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What is your type of residence?
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Years spent at residence?
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Months spent at residence?
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What type of property is it?
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Are you the owner of the property?
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Are you living in the property?
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Property ZIP code
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Property address
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What is the municipal Lication?
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What is the type of occupancy?
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Is the property newly purchased?
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What is the foundation status?
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What kind of garage?
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How many bathrooms?
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How many bedrooms?
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Is Home Security available?
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Is a Fire Alarm available?
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What is the Story Level?
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What type of roof?
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How old is the roof?
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When was the property build?
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When was it last upgraded?
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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?
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What is the Type of Construction?
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What type of panel?
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Proximity water distance?
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What is the primary heating type?
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What type of exterior walls?
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What kind of wiring?
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Dog in house?
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Features:

Deadbolts available?
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Fire extinguisher available?
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Is there a swimming pool?
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Is the swimming pool fenced?
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Is there a trampoline?
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Floodplain available?
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Covered deck or patio available?
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Is there a fireplace?
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Is there aire station within 5 miles?
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Is there a fire hydrant within 1000 feet?
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Indoor sprinklers installed?
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Copper water pipes installed?
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Brush hazard within 500 feet?
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Central air condition installed?
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Is there a sauna?
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Hot Tub available?
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Wood burning stove available?
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Is there a sump pump?
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Is there a smoker in household?
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Policy Current:

Are you currently insured?
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Current Insurance Company
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Current coverage package?
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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?
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Type of Claim
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Date of Claim
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Amount Paid in USD
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