* Name
* Date of Birth
Spouse's Name
Spouse's Date of Birth
* Email
* Home Phone
Work Phone
* Street Address
* City
* State
* ZIP
Street Address
City
State
ZIP
* Dwelling
* Liability (select) $300,000 $500,000 $1,000,000
* Deductible (select) $500 $1,000 $2,500 $5,000
* Year Built
Market Value
* Occupancy (select) Primary Dwelling Secondary/Cottage Rental Property Vacant
* Construction (select) Frame with Wood Siding Frame with Vinyl or Aluminum Siding Frame with Brick Exterior
* Pool (select) None Above Ground Below Ground Below Ground with Diving Board Below Ground With Slide Below Ground with Diving Board and Slide
* Woodstove (select) None Yes - In Home Yes - Outside, less than 25 ft from home Yes - Outside, Over 25 ft from home
* Type Of Roof (select) Composition Shingle Metal Slate Wood Other
* Age Of Roof (select) 1-5 Years 5-10 Years 10-15 Years 15+ years
* Age Of Furnace (select) 1-5 Years 5-10 Years 10-15 Years 15+ years
* Hydrant Distance Less Than 1000 ft Over 1000 ft
* Fire Station Distance Less Than 5 mi Over 5 mi
* Smoke Detectors Yes No
* Fire Extinguisher Yes No
* Central Alarm Yes No
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