| GENERAL INFORMATION: |
| *Name: |
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| *Current Address: |
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| *City: |
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| *State: |
*Zip Code:
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| *Policy Number |
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| *E-mail address: |
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| *Home Phone Number: |
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| *Daytime Phone Number: |
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If you have made any of the following changes to your home since we last reviewed the replacement value of your home
please call us or complete this form and return it to us. |
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Built an addition |
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Changed type of doors or flooring (i.e. carpet to hardwood) |
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Upgrade kitchen, bath |
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Finished your basement, attic |
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Built a shed, deck, or porch |
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Added pool, trampoline |
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Added woodstove |
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Added security system |
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Increased your personal property above value shown on declarations |
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Notate which of the following endorsements you would like added to or deleted from your policy.
Your change will be effective as of the date signed unless otherwise requested. |
| Enhancement Endorsement (combines Sewer & Drain backup, Law & Ordinance and more) |
Add
Delete |
| Siding & Roof restoration (limit max $20,000) |
Add
Delete |
| Amount: |
$10,000
$15,000
$20,000 |
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| Replacement cost personal property |
Add
Delete |
| Sewer & Drain Backup |
Add
Delete |
| Deductible: |
$100
$250 |
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| Law & Ordinance |
Add
Delete |
| Increased Loss Assessment (limit max $50,000) |
Add
Delete |
| Limit: |
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| Earthquake Coverage |
Add
Delete |
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| If you would like coverage for any of the following items please send us a copy of your current appraisal/s (less than 2 years old). |
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Jewelry (in excess of $3000) |
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Guns (in excess of $3000) |
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Furs |
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Fine Art |
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Income Protection |
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Musical Instruments |
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Other (please specify)
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| Is the mortgage company listed showing the correct address and loan number? |
Yes
No |
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If not please provide the correct information.
(Please note that most companies have a different address for insurance
than your mortgage payment.) |
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| Do you have any pets or animals? |
Yes
No |
| Type: |
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| Breed: |
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| Number: |
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| Are you using any space in your home for business? |
Yes
No |
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If yes, what type?
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What is the value of your business property?
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| Are there any other coverages you want to discuss such as: |
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Life |
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Health |
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Long Term Care |
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Auto |
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Flood |
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Umbrella |
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Recreational Vehicle |
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| Would you like to schedule an appointment with one of our agents? |
Yes
No |
Additional Comments
or questions: |
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