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Dwelling Quote
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Home Owner
Secondary Home
Dwelling Fire (Rental)
Tenant HO (Contents only)
Personal Information
Name
*
Spouse Name
*
Mailing Address
*
Phone # (Best contact #)
*
Phone Type
*
Home
Cell
Work
Personal Information
*
SS#
DOB
Email
Spouse Information
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SS#
DOB
Email
Property Information
Address
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Street Address
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ZIP Code
Home Replacement Cost (excluding land): $
*
Deductible: $
*
Liability Limit: $
*
Property Information (Year Updated)
*
Year Built
Roof
Plumbing
Wiring
Heat A/C
What is the primary construction type of the home?
*
Brick
Frame
Cement Hardie Board
# Stories
*
# Years at this address
*
Slab?
*
Yes
No
Crawl Space?
*
Yes
No
Property Information (Enter # Square Feet)
Heated Space (exclude Basement)
*
Heated Space – Finished Basement
*
Unfinished Basement
*
Add each Porch / Square Feet (Click “+” to add each porch on the property)
*
Porch (front/side/rear)
Porch (# Square Feet)
Add each Deck / Square Feet (Click “+” to add each deck on the property)
*
Deck (front/side/rear)
Deck (# Square Feet)
Property Information (#)
*
# Fireplace Inserts
# Masonry
# Full Baths
# Half Baths
Carport or Garage?
*
None
Carport
Garage
Number of Vehicles
*
1
2
3
4
5
Gas logs?
*
Yes
No
Central heat?
*
Yes
No
Wood stove or Space htrs?
*
Yes
No
Central air?
*
Yes
No
Trampoline?
*
Yes
No
Pool?
*
Yes
No
Fenced?
*
Yes
No
Dogs?
*
Yes
No
Number of Dogs?
*
Breeds?
*
Central or Local Alarm?
*
Yes
No
Alarm Type
*
Burgular
Fire
Monitored by:
*
Deadbolts?
*
Yes
No
Fire extinguishers?
*
Yes
No
Smoke detectors?
*
Yes
No
Smokers in household?
*
Yes
No
Name of responding Fire Dpt?
*
Road miles to Fire Dpt:
*
Hydrant w/in 1,000 ft?
*
Silver Limit $
*
Gun Limit $
*
Boat or ATV?
*
Yes
No
Mortgagee (Name/Address)
*
Current Insurance Information
Current Home Insurance Company
*
Policy Number
*
Expiration Date
*
MM slash DD slash YYYY
Have you been non-renewed/cancelled?
*
Credit problems/Bankruptcy?
*
Describe any claims in the past 6 years
*
Current Umbrella Policy Limit
*
None
$1M
$2M
$3M
$4M
$5M
How did you hear about Chastain & Associates Insurance?
*
UPLOAD CURRENT HOME POLICY
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