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General Info:
First Name			Last Name
Address of Property			City
State			Zip
Home Phone			Work Phone
*Email			Referred By
Property Info:
Square Footage			Number of units
Dwelling Value			Construction Type		Frame Masonry Superior Masonry Veneer
Year Built			Roof Type		Asphalt Shingle Tile Slate Wood Shake Metal Other
Fire and Theft Information:
Over 1000 feet from a fire hydrant?		Yes No	Deadbolts		Yes No
Fire Department Location			Type of fire sprinklers		None Full Partial
Distance to nearest fire station			Type of fire alarm		None Local Station
Fire Extinguisher		Yes No	Type of theft alarm		None Full Partial
Smoke Detector		Yes No
Requested Coverages:			Policy Information:
Liability coverage		$100,000 $300,000 $500,000	Have you filed a previous homeowners claim?		Yes No
Medical payments		$1,000 $5,000 $10,000 $25,000	Date of last claim
Policy deductible		$250 $500 $1,000 $2,500	Current policy with
			Current policy expires

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