Homeowner Insurance Quote Questionnaire


Name
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E-Mail
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Phone #
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Location Address
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City
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State
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Zip
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Location and Mailing Same?
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If no form above, Mailing Address
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City
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State
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Zip
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DOB
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SSN #
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Year Built
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Occupancy
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Construction
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Prior Insurance Company
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Renewal Date
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Forced Placed Insurance?
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New Purchase?
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If New Purchase, Closing Date
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Roof Construction
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# Of Stories
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If over 1 story, construction of upper floors
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# of Baths
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Size of Garage (Cars)
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Fireplaces
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Pool
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If there is a pool, slide?
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If there is a pool, diving board?
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Is the pool fenced?
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Is the pool screened?
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Any Dogs?
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If yes to dogs, how many?
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If yes to dogs, breed
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If yes to dogs, biting history?
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Please list other structures (sheds, fences, detached garages, etc.)
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Does the home have




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Updates
Roof
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Electric
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Plumbing
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Windows
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Any Previous Claims?
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If yes to previous claims, please list
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Previous Address
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Contact Us

Sandbergen Insurance, Inc.
2121 N. E. Coachman Rd.
Clearwater, FL 33765
Map and Directions

Tel: 727.442.0012
Fax: 727.446.9147

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Independent Insurance Agency Serving the Entire Tampa Bay
Copyright 2010 Sandbergen Insurance

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