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First Name

Last Name

Insured Name

Oldest Insureds DOB

Email

Phone Number

Home Address

Building Sum (Replacement Value)

Contents Sum

External Wall Construction

Roof Construction

Year Built

Do all external doors have deadlocks?

Do all windows lock with a key?

Do you have an alarm? If yes, Local or B2B?

Policy Start Date

Preferred Excess (Standard is $600)

Finance/Mortgagee Name

Have you been declined insurance in the past? Have you had any criminal convictions? Have there been any building and/or contents claims on this or any other property in the last 5 years? If yes, provide more details.

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