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Home Owners Insurance Request for Quote*

. . .
Fill in the form below with as much of your information as possible.
*Please Note:  Submitting this quotation request does not bind coverage. 		.
Mailing Address:   .
Owner’s Name (First, Middle, Last): .
Date of Birth: .
Co-Owner’s Name (First, Middle, Last): .
Date of Birth: .
Address: .
City: .
State: .
Zip: .
Home Phone #: .
Work Phone # and Extension: .
Email: .
Fax #: .
Best time to call: Morning Afternoon Evening .
Best way to reach: Phone Fax Email .
Property Address if different from above:   .
Address: .
City: .
State: .
Zip: .
Is this a new quote for your existing house?: .
Is this a new quote for a newly purchased home?: .
Current Coverage -- If you have a policy in force, please fill in the following: .
Condo Dwelling Coverage A: .
Other Structure Coverage B: .
Personal Property/Contents Coverage C: .
Loss of Use Coverage D: .
Personal Liability Coverage E: .
Medical Payments to Others Coverage F: .
Deductible: $250 $500 $1000 $2500 .
Do you have guaranteed replacement cost on contents? Yes No .
Do you have guaranteed replacement cost on dwelling? Yes No .
Additional Information:   .
Age of Home: Years .
Number of Families: .
Total Square Footage of Dwelling (if known): .
Attached Garage: .
Detached Garage: .
Do you have the following? .
Dog? Yes No .
Type: .
Swimming Pool: Yes No .
Premise Alarm: Yes No .
Smoke Detectors: Yes No .
Are you a non-smoker?: Yes No .
Are all the members of your household non-smokers? Yes No .
Scheduled Property (Enter an amount for all that apply) .
Golf Equipment: .
Cameras: .
Musical Instruments: .
Silverware: .
Furs: .
Guns: .
Jewelry: .
Fine Arts: .
Other: .
In Home Business? .
In Home Business: Yes No .
If Yes, type of business: .
Any homeowner losses in the last three years? Yes No .
If yes, list approximate year, dollar amount and description of loss: .
1. .
2. .
3. .
Comments: .
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A member of Renaissance Alliance Insurance Services.

Markham Priest Insurance • 20 Central Ave. • P.O. Box 310 • Ayer, MA 01432
Phone:  1-800-971-0800 • Fax:  978-772-9506
Office Hours • Monday - Friday: 8:00 am - 5:00 pm or By Appointment
To learn more about Markham Priest Insurance, please download our company brochure.

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