First: M.I.: Last:
Home Phone #: Work Phone #:
Social Security #:
Approx. age of house:
Was the house purchased within the last 12 mos.? (y/n)
Is the house over 2/3 brick? (y/n)
Do you have a security system installed? (y/n)
Current coverage amount:
Losses (if any) in the last three years:
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