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» POLICY HOLDER |
| first name: |
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| last name: |
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| address: |
of location to be insured |
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| city: |
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state: |
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zip: |
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| phone: |
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| e-mail: |
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» PROPERTY |
| year built: |
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| construction: |
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| # of units: |
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| losses: |
paid by insurance company
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| distance to fire house: |
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| distance to fire hydrant: |
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| Do you own a dog? If so, what breed? |
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| personal liability limit: |
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| personal property limit: |
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| deductible: |
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| additions & alterations: |
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Fill in an amount in thousands (ie 10,000) or write the word “standard” if you’re not sure of the amount you want |
| loss assessment |
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Where did you hear about us?
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