Select Recipient ---Barry Sturgis - Commercial AgentRoger L. Stevens, Jr - Commercial AgentStephanie Reid - Commercial AgentDawn Brennan - Personal Lines AgentHeidi Lagomarsino - Personal Lines AgentPaula Cheatham - Personal Lines AgentVanessa Vargas - Personal Lines Agent
First Name (required) Last Name (required) Street Address: Apt#: City: State: Zip: Phone: Email address:
Best time to contact: AM/PM Select OneAMPM
Do you currently have homeowner insurance? Select OneYesNo
Expiration date of your current Homeowners Insurance Policy? (MM/DD/YY)
Do you own or rent? Select OneOwnRent
Current insurance value of your home? $
Year Built? Square Footage
Construction Type: Select OneWood FrameBrinkMasonary
Is there a woodstove in your home? Select OneNoYes
Do you have a garage Select OneNoYes Is it attached Select OneNoYes
If you have a garage, how many cars?
What is the distance from a fire hydrant? Select One-500 ft.-1000 ft.+1000 ft.
How many miles to the nearest Fire Department?
Personal liability limit? Select One$100,000$300,000$500,000
Deductible for property coverages? Select One$250$500$1,000
What is the replacement cost value of your personal items?
What deductible would you prefer for your rental policy? Select One$250$500$1,000
What are your personal liability limits for your rental policy? Select One$100,000$300,000$500,000
Additional comments or questions
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