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a common sense approach since 1984

First Name
Last Name
Address Line 1
City
State
Zip Code
Daytime Phone() -
Evening Phone() -
Fax() -
E-mail Address
Year Built
Square Footage
1 or 2 Stories
Slab or Raised Foundation
Frame Stucco Y N
Number of Fireplaces
Type of Roof (Comp/ Tile/ Wood)
Is there a pool ?
2 or 3 Car Garage
Do you have a Central Station Alarm ?
Any Claims in the past three years ?
Present Carrier, Experation Date and Premium
Would you like a quote on Earthquake Insurance ?
Would you like a quote on Mortgage Insurance ?

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