• Personal Information

  Name
  Date of birth
  Mailing Address
  Address (cont.)
  City
  State/Province
  Zip/Postal Code
  Work Phone
  Home Phone
  FAX
  E-mail
  Please contact me via:	Email Telephone Fax

• Physical Address of Property (Complete ONLY if different from Mailing address above)

   

• Distance from ocean

  More than 1 mile

  Between ½ mile to 1 mile

  Less than ½ mile but at least 1 building separation between your home and the ocean

  Oceanfront

• Please indicate whether home is a Primary or Secondary Residence 

  Primary

  Secondary  -  ABSOLUTELY NO Rental

  Secondary  - Seasonal / Short Term  Rental

           # of weeks rented

  Year round Rental Property

   

• Year of Construction 

  If home is over 30 years old please indicate when updates last done to roof, heating, electrical, & plumbing

• Type of Construction 

  Frame

  Masonry

  Modular (e.g. Nanticoke)

• Property Value to Insurance (Replacement Cost)  

  Condominium	Contents $
  	Building Additions $
  Home	Building $
  	Contents $
  Renter	Contents $

• Protection Class  

  less than 5 miles from nearest fire station

  less than 1000' from nearest fire hydrant

   

   

   

   

   

• Loss Information 

  Please advise whether you have suffered any losses in the past 5 years. If none, please check the box below. Otherwise, please enter complete loss details in box to the right                   None

• Flood Insurance

  Please indicate you are interested in receiving a Flood Insurance Quotation 

  by checking this box  

   

• Comments

• Agent requested

            First available Anthony DiMarzo Chuck Riley J W Hocker Janet Dunn Katie Steighner Nancy Miller Patty Walker Robin VanBruggen Seth Costello Warner "Bud" Clark Other - See Comments