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Homeowners Insurance Quote Form |
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Insurance Center of Buffalo |
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Personal Information: |
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1st Named Insured |
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Date of Birth: |
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SSN: |
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Home Phone: |
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Cell Phone: |
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Email: |
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2nd Named Insured: |
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Date of Birth: |
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SSN: |
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Home Phone: |
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Cell Phone: |
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Email: |
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Mailing Address: |
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Township: |
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County: |
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City/State |
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Zip Code: |
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Current Insurance Information:
Current Deductible: |
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Liability Limit: |
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Current Insurance Carrier: |
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Current Dwelling Amount: |
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Policy Start Date |
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Known Losses (past 5 years): |
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Home & Property Information:
Physical Address:
Year Constructed:
# Living in Home:
# OF FAMILIES: 
Miles from Fire Dept. |
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Responding Fire Dept. |
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Fire Hydrant Near: |
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Inside City Limits? |
YES |
NO |
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Wood Stove: |
YES |
NO Fireplace: |
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Age of Roof (Years): |
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Roof Type: |
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Above Ground Sq. Footage: |
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House Style: |
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% of Basement Finished: |
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Walkout Basement: |
YES |
NO Age of Plumbing (Years): |
# Full Bath: |
# ¾ Bath: |
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# ½ Bath: |
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Heat Source & Type: |
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Age of Heat Source (Years): |
A/C Central Air: |
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YES |
NO |
Age of Electrical (Years): |
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Kitchen Type: |
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Specialized Doors: |
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Other Special Features: |
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Business Usage: |
YES |
NO |
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Garage: |
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Garage Size: |
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Attached Structures: |
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Size of Structure: |
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Security System: |
YES |
NO |
Attached Structures: |
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Size of Structure: |
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Total Acreage: |
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Other Attached Structures: |
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Size of Structure: |
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Trampoline: |
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Swimming Pool: |
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YES |
NO |
Pool Type: |
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Pool ([WUDV: |
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Pets (LIST BREED) |
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Outbuildings? |
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If yes, please enter type, size, and value for each:
High Value Items?
Please enter all details for any
Collectibles, Art, Jewelry, Guns,
ATVs, Snowmobiles, Boats, Etc.:
Any Additional Comments:
PHONE: |
763-682-4890 |
EMAIL: |
INFO@INSURANCECENTEROFBUFFALO.COM |
FAX: |
763-684-5278 |
ADDRESS: |
PO BOX 458, BUFFALO MN 55313 |