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YOUR
INFORMATION |
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Full
Name: |
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Address:
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City*:
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State*:
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Zip:
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Email:
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Fax:
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Phone:
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Work
Phone:
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Best
Time
to
Call*:
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CURRENT
INSURANCE
INFORMATION: |
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Current
Insurance
Carrier*:
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Expiration
Date:
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Deductible:
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CURRENT
INSURED
VALUES: |
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Dwelling: |
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Personal
Property: |
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Personal
Injury: |
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Earthquake
Deductible: |
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Personal
Liability:
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Medical
Payments:
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Earthquake
coverage:
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Policy
Type:
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Number
of
Units:
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Number
of
stories:
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Year
Built*:
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Square
Feet:
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Construction:
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Foundation:
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Type
of
Roof:
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Last
replaced:
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Plumbing:
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Last
update:
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Electrical
System*:
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Last
updated:
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Central
Alarm*:
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Heating:
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Last
update:
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Central
Air*:
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Last
update:
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Number
of
Fireplaces*:
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Number
of
bathrooms*:
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Full
Half |
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Garage*:
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Number
of
car
garage:
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Size
of
Decks:
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Swimming
pool:
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Brush
Area:
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Current
Earthquake
Damage:
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Prior
losses
past
5
years:
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Bankruptcy
ever
filed?
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Occupation:
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Employer
Address:
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Emp.
City:
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State:
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Zip:
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QUESTIONS
OR
COMMENTS |
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