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Homeowners Quote
 

Thank you for requesting a homeowners quote. Please fill out all applicable areas of the application.  Field marked * are required.

Personal Information
Name:
Address:
Address (second line):
                              City: State: Zip:
County:
Email:
Day Time Phone:
Night Time Phone:
Other Phone:
Best Time to Call:
Contact Preference:
Social Security #:
Occupation:
How Long:    Years Months
   

Current Homeowners Insurance Company
Company Name:
Policy Exp. Date:
Amount Insured For: $
      Premium:$
                            Term: 6 Months 1 Year Other
   

Home Information
Length at present address: Years Months
Sq. footage of home:   Year home was built:
# of claims in last 3 years:
   

Structure  Information
Type:                  Construction:             Roof:                        Foundation:
      

Garage:           Age of Roof:yrs
   

Structure  Information

    Bathrooms:           Basement:        Deck/porch/patio:        Fireplace:
 # of full             Deck sq ft: # of Chimneys:
 # of half     Sq. Ft.    Porch sq ft:    # of Hearths:
                                              Screened patio sq ft:
   

 Additional Features

Heating System: Central Air: Yes No  Central Vac: Yes No

  Security Alarm:   Fire Alarm:

Smoke Detector:Yes No
   
Additional Comments:
   

 

124 Seneca Way    Map
Ithaca, NY 14850
Tel: 607-273-7511
Fax: 607-273-7571
Email to: jay@trueinsurance.com

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