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* Required Fields

General Information
First Name * MI Last Name*
Street Address *
City* State Zip Code* Birth date(mm/dd/yyyy)*
Phone - - Email Address*
Property Information
# of Families*
 Style
 Occupancy*
 Exterior*
Year Built*
 Total Living Area Square Ft *excluding basement & garage Construction Quality

Basement

%Finished

Garage

# of Cars

 # of Full Baths
# of Half Baths 		Fireplace
Material 		Deck
Square Ft
Heating System AC
Using heat ducts? 		   
Year Updated

*Required for homes over 20 years old.

Roof*
Electricity*
Heat*
Plumbing*
Credits
Smoke Alarms Deadbolt Locks Fire Extinguisher
Sprinklers in unit/whole house Central Station Burglar Alarm Central Station Fire Alarm
Coverage Information
Dwelling Amount*
Liability*
Water Back-Up*

Scheduled Articles:
Jewelry ----- Silverware ----- Furs ----- Fine Arts

Other Endorsements

Claims Information
Have you filed any homeowners claims in the past 5 years?* If yes, please list below.
Date (mm/dd/yyyy)
Description
Amount Paid
Current Insurance Information
Insurance Company Expiration Date
Remarks

By submitting this request, you authorize Faller Insurance Agency to order your Consumer Report. The quotation you will receive will be based on your Consumer Report and claims information you provide us.