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 POLICY HOLDER |
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| Last name: |
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| Address: |
of location to be insured. |
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State: |
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Zip: |
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| Phone: |
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PROPERTY |
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| Losses: |
paid by insurance company. |
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| Oil tank: |
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If built over 20 years ago, we will need renovation or replacement dates for your roof, plumbing, electrical system, hot water heater, and main heating system. Examples of these would include replacing toilets or a kitchen sink, replacing lighting fixtures, increasing amperage of electrical service, or having an annual service performed on the water heater or main heating system. |
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Roof: |
month/year (xx/xxxx) |
Plumbing: |
month/year (xx/xxxx) |
Electrical: |
month/year (xx/xxxx) |
Hot water heater: |
month/year (xx/xxxx) |
Heating system: |
month/year (xx/xxxx) |
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Alarm: |
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Distance to fire house: |
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Distance to fire hydrant: |
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Do you own a dog? If so, what breed? |
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Personal liability limit: |
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Personal property limit: |
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Deductible: |
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