First Name
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Phone Number
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Last Name
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Email Address
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Date of birth
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Marital Status
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Occupation
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If married, spouse's date of birth
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Address
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City
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State
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Zip
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Property location (if different)
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Township
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County
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Year built
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Number of families
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Responding fire department
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Property type
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  • Primary
  • Seasonal
  • Rental
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Primary heat source
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  • Electric
  • Gas (line)
  • Oil
  • Gas (Tank)
  • Wood
  • Other
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Used for business?
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Square Footage
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Number of stories
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Basement
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Any updates on the below recently (mark with year updated)
Wiring
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Plumbing
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Heating
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Roof
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Coverage needed
Dwelling:
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Loss of Use
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Other Structures
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Liability
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Contents:
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Medical Pay:
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Deductible:
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Previous Carrier
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Policy Number
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Leinholder:
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Consider an Insurance “Tune-Up” for 2023

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