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*Name: Phone:
*City: , *State: *Zip:
Primary Residence: Y N If not, months occupied:
Length: Width: Year of Home:
New Purchase: Y N If not, Prior Insurance: Y  N   Carrier:
Any homeowners claims in the past 5 years? Y N  
Is the home in a mobile home park or private property? Park Private property
Central Heat/Air: Y N East or West of Hwy 19? East West
Any Pets? Y N If so, what kind?
Is home fully skirted? Y N
If no, we cannot write.
Do all steps 3 or higher have handrails? Y N
Replacement cost of home:
(Amount needing insured for)