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(415) 555-5555
180 Jefferson Drive
Menlo Park, CA 94025
(415) 555-5555
Monday - Friday 8AM to 5PM
Securing your Family's
Future & Finances
Copyright© 2008 Vickery Insurance Agency, Inc.
Effective Date:
Your Name:
Your Property Address:
E-Mail Address:
Phone #:
Preference:
Current Coverage:
Current Company:
Expiration Date:
Type of Policy Desired:
Amount of Insurance Desired:
Home Owners Only
Trampoline:
What is your property Value:
Condo/Renters Only
Swimming Pool:
Liability Limit:
Medical Payments:
Deductible:
Value of Home:
Personal Property Value:
Construction Type:
Year Home Built:
County:
Distance to nearest Fire Hydrant:
What kinds of pets do you have:
Use Wood Burner:
Smoke Detector/s:
Home Security System:
Home Updates enter years updates were made:
Roof:
Plumbing:
Wiring:
Heating:
Property Floaters:
Antiques:
Computers:
Fine Arts:
Furs:
Jewelry:
Tools:
Previous Loss Information:
Please describe any losses or claims filed on your homeowners Insurance in the last 5 years, type of loss and amount of claim.
Additional Comments:
Your Agent:
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