First Name:
Last Name:
Address:
City:
State:
Zip Code:
Phone(Daytime):
Phone (Other):
Email:
Do you currently have insurance?
Yes No
If "Yes", when does your current policy expire?
If "Yes", who is your current provider?
If "Yes", what is your premium?
If "Yes", what is your condo insured for?
Year Purchased:
Purchase Price:
Approximate Interior Square Footage:
Approximate Year Built:
Is your condo located within 500 ft of a fire hydrant?
Yes No
Is your condo located within 5 miles of a fire station?
Yes No
Is your condo susceptible to flooding or high water?
Yes No
Is your condo built on a hillside?
Yes No
Is your area prone to landslides and/or sinkholes?
Yes No
Is your condo located within a brush hazard area?
Yes No
Do you have a dog?
Yes No
If "Yes", how many dogs do you have?
If "Yes", what breed(s) is the dog(s)?
Are there any firearms in your condo?
Yes No
Is there a central alarm system?
Yes No
Have you filed any claims within the last 5 years?
Yes No

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