| General Information |
| How do you want the quote returned? |
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| Type of Policy |
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| Number of Families |
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| Your Name |
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| Town/ City |
, Massachusetts |
| E-Mail Address |
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| Phone |
()- |
| Fax |
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| Coverage Selections |
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Please choose one from each coverage. Coverage A (Dwelling), B (other structures), C (personal property) and D (loss of use) can only be calculated after we receive this quote.
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Deductible
Please choose your deductible. The higher the deductible the less your policy will cost. |
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COVERAGE "E": Personal Liability
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COVERAGE "F": Medical Payments
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Renters/ Condo(Only)
Personal Property Coverage
(please select whether you rent or own a condo or townhouse)
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| Residence Questions |
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In order to provide the most accurate quote please answer the following questions as best you can.
Dwelling Replacement Amount (Homes Only)
If you have a dwelling replacement amount you want us to quote on please state below. Otherwise we will take the information you provide below to come up with a dwelling coverage limit.
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| Desired Dwelling replacement Amount (Coverage "A"): |
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| How Many Floors: |
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| Square Footage (first floor only) if available: |
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I do not know. The above footage represents TOTAL square footage.
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| Year Constructed: |
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| Exterior: |
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| Distance From Ocean: |
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| Heating Source: |
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| Garage |
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| If Older Home State Updates (last 20 years) |
No updates done |
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Roof |
year updated |
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Plumbing |
year updated |
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Electric |
year updated |
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Heating |
year updated |
| Check Boxes That Apply (answering thoroughly insures proper discounts/ coverage): |
| Guaranteed Replacement on Contents |
Guaranteed Replacement on Dwelling |
Fireplace |
Deck(s) |
| Porch(es) |
In Home Business |
Burglar alarm |
Smoke alarm system |
| Sprinkler System |
Deadbolts |
Non-Smoker |
Age 49 and older |
| Other properties owned |
Home computer |
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