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Date of Birth *
Marital Status *
Number of stories *
Dwelling Type *
Number of Car Garage *
Type of Garage *
Number of Kitchens *
What Grade is The Kitchen(s) *
Number of Full Bathrooms *
What Grade Are The Full Bathrooms *
Number of Half Bath *
What Grade Are The Half Bathrooms *
How Many Fireplaces?
Central Burglar Alarm?
Central Fire Alarm?
Interior Fire Sprinklers? *
Please provide with the Percentage of Each. All must equal to 100%.
Do You Currently Have Insurance?
Claims/Property Losses in Past 5 Years (Please Explain)
How Did You Hear About Us?
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