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FIRST NAME *

LAST NAME *

ARE THEIR DOGS ON THE PREMISES? IF YES, WHAT BREED? *

PROPERTY ADDRESS WITH ZIP CODE *

APPROXIMATE AGE OF BUILDING *

WHAT TYPE OF PROPERTY IS THIS? * SINGLE FAMILY HOMECONDO4 PLEXAPARTMENT COMPLEX DUPLEX

DO YOU RUN A BUSINESS OUT OF YOUR HOME? (INCLUDING A DAYCARE) * YESNO

WHICH MATERIALS ARE ON THE OUTSIDE OF THE HOME? * BRICK OR STONEWOOD/FRAMEALUMINUMVINYL SIDINGOTHER/ I DON'T KNOW

DO YOU HAVE A FIRE ALARM? * YESNO

ANY TYPE OF ANTI-THEFT ALARM? * YESNO

HOW MUCH COVERAGE WOULD YOU NEED IF YOU HAD TO REPLACE ALL OF THE CONTENTS IN YOUR HOME DUE TO A LOSS? * 10,00015,00020,00025,00030,00035,00040,000

IF YOU HAD A COVERED LOSS THAT DAMAGED SOME OR ALL OF THE CONTENTS IN YOUR HOME WHAT WOULD BE THE MAXIMUM YOU COULD PAY OUT OF POCKET? * 200250500100015002000 OR MORE

HOW MUCH LIABILITY COVERAGE DO YOU NEED? * 25,00050,000100,000

DO YOU OWN ANY: FURS, EXPENSIVE SILVERWARE, ELECTRONICS, FIREARMS, OR ANY OTHER CONTENTS YOU NEED TO LIST SEPERATELY? IF YES, LIST THE ITEMS INDIVIDUALLY WITH THEIR INDIVIDUAL PURCHASE PRICES. *

ANY EXPENSIVE ITEMS IN YOUR HOME SHOULD BE SCHEDULED ON YOUR POLICY TO ENSURE PROPER COVERAGE.

WILL THERE BE A SECOND NAMED INSURED? * YESNO

SSN (OPTIONAL)

YOUR SSN IS RECOMMENDED FOR A MORE ACCURATE QUOTE (SOMETIMES A BETTER RATE CAN BE GIVEN DEPENDING ON YOUR INDIVIDUAL INSURANCE SCORE) BUT IS NOT REQUIRED

YOUR DATE OF BIRTH *

OCCUPATION *

PHONE NUMBER *

EMAIL *

HOW DID YOU HEAR ABOUT AFFORD A SURANCE? * YAHOO SEARCH ENGINEGOOGLE SEARCH ENGINECUSTOMER REFERRALI'M A CURRENT CUSTOMERAFFORD A SURANCE COMPANY SIGNS OR BANNERSTHE FEISTTHE USER FRIENDLY PHONE BOOK

HOW WOULD YOU LIKE TO BE CONTACTED REGARDING YOUR QUOTE? * PHONEEMAILU.S MAILANY OF THE ABOVE

YOUR AGENT WILL CONTACT YOU REGARDING YOUR QUOTE WITH YOUR PREFERRED METHOD OF CONTACT.

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