form preview page - Hometown Insurance Agency

Agent

Are you in a union, association, or municipal volunteer or employee? *YesNo

Organizations Name *

First Name *

Last Name *

Occupation *

Date of Birth *

Month

Day

Year

Email Address *

Phone Number *

Mailing Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country *

Is your property address the same as your mailing address above? *YesNo

Property Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country *

Home Type *

Construction Type *

Year Built *

Purchase Year *

Year of Major Electrical Updates

Year of Major Plumbing Updates

Year of Major Roof Updates

Living Area Square Footage *

Primary Heating *

Primary Heating Type *

Foundation *

Oil Tank Location (If applicable)

Roof Material *

Roof Age *

Roof Shape/Style *

Stories *

Bedrooms *

Bathrooms *

Garage Type *

Solar Panels *YesNo

Do you have an existing policy? *YesNo

Have you reported any claims or losses to your insurance company within the past 5 years? *YesNo

Do you own a dog? *YesNo

Dog Breed and Bite History

Do you have a pool? *YesNo

Does the pool have a diving board and/or slide? *

Do you have a Trampoline? *YesNo

Do you run a business from home? *YesNo

What type of business? *

Current dwelling limit or approximate cost of replacement (found on dec page) *

USD

Desired Deductible *

Personal Liability Coverage Desired *

List all legal name/s on the property deed:

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