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Contact Name *
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Property Location
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Current Insurance Information
Company Name
Current Annual Premium
Expiration Date
Deductible Desired
$100
$250
$500
Amount of Liability
$100,000
$200,000
$500,000
$1,000,000
Earthquake Coverage Desired?
Yes
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Have you filed for bankruptcy within the past 7 years?
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No
Dwelling Information
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Square Footage
Year Constructed
How Many Floors?
1 Story
1.5 Story
2 Story
Bi-Level
Tri-Level
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Type of Construction
Wood
Stucco
Masonry
Brick Veneer
Aluminum Siding
Other
Other Features
(check all that apply)
Dead Bolts
Smoke Detectors
Fire Extinguisher
Central Station Fire Alarm
Central Station Burglar Alarm
Home Located within 5 miles of Fire Station
Home Located within 1000 feet of a Fire Hydrant
Swimming Pool
Trampoline
Home located within City Limits
Claims
List any claims in past 3 years:
Amount Paid
Claim Type
Description
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2.
3.
Personal Property
Estimated value of your personal property:
Jewelry & Watches
Furs
Silver
Firearms
Stamp and Coin Collections
Fine Arts and Breakable Items
* = Required Field
Disclaimer Notice
- The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.
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1296 Westgate Parkway
Dothan AL 36303
(334) 793-0014
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