Professional Documents
Culture Documents
Name: ____________________________
Policy #________________________________
Postal Code:___________________________
Phone #___________________________
E-mail address:__________________________________________________________________
What is your primary source of heat? Natural Gas Oil Electric Woodstove Other________
60amp
100amp
200amp
Yes or No
What is your lawyers name and phone number (if this is a new purchase)
_______________________________________________________________________
Close Date___________________
If you are new to our office and you have moved in the last 3 years, please provide your previous
address_________________________________________________________________________
If you are new to our office, please advise if you have had prior property insurance of any kind and
for how many continuous years?_____________________________________________________
What is your prior insurance company name and policy number?____________________________
Yes or No
How many families are residing in the home? ______ Any roommates or boarders? Yes or No
Have you had any claims in the last 5 years?
Yes or No
_______________________________
Yes or No
Yes or No
Date of Birth:_________________________
REMARKS:______________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________