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Home Insurance quote

Client Info

Name    Address

City    State     Zip

Daytime phone     Best time to call    AM    PM 


Occupation     For how long?

Current Home Insurance Info

Company name     Policy expiration date

Premium amount $     Amount insured for $     Policy type


Home Info

How long at present address?     Year home was built

Square footage (not counting garage)    Number of claims in the past 3 years

Has the home had a sinkhole?

Has the sinkhole been repaired?

Structure Info

Type     Construction     Roof

Garage     Style     Foundation


Bedrooms     Bathrooms     Other rooms     Square footage

Fireplace     Chimneys     Hearths     Pool

Safety fence     Trampoline     Central heat/air     Heat pump

Window air     Fire alarm     Smoke detector     Security system

Jacuzzi     Hot tub


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