Personal Information

First Name *

Last Name *

Email *

Home Phone

Work Phone

Address 1

Address 2

City

StateALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Zip

Property Information (if different from your home address)

Address 1

Address 2

City

StateALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Zip

This coverage is for your:
 Home Apartment or Rental Condo or Co-op

Do you:
 Own Rent

Residence usage:
 Primary Secondary

Do you own a dog?
 Yes No

If yes, what breed?

Is there an underground fuel storage tank on premises?
 Yes No Don't know

Is any business conducted on the premises?
 Yes No

If yes, please describe:

Property Information (cont.)

Year of construction:

Type of construction:
 Frame Brick Log Other

If other, please explain:

Protection devices installed:
 Smoke detectors Fire extinguisher Central burglar/fire alarm Dead bolts

Is the property within city limits?
 Yes No

If no, in what fire district is it located?

Distance in road miles to the nearest fire department:

Distance in feet to the nearest fire hydrant:

Coverage Information

Dwelling coverage limit: $

Property Deductible:
 $250 $500 $1000 $2500

Liability Coverage Limit:
 $300,000 $500,000 $1,000,000

High value items (item, value):
These are items that need to be specifically identified, included jewelry, silverware, collectibles, furs, etc. Please list each item and its value.

What is the effective date of your current policy?
mm/dd/yyyy

Have you had any claims during the last three years?
 Yes No

If yes, please explain briefly.

Home Insurance Available Discounts

Please indicate which of the following apply to you:
 Employee of the Town of Lee, MA Employee of Schweitzer-Mauduit International - Lee Mills Member of Greylock Federal Credit Union Home/Auto Package (insuring both home and auto with us) Central Station Reporting Alarm System Sprinklers

We will reply with your customized insurance quotation by the close of the next business day. After delivery of your quote, we can at your request call you to answer any questions you may have.

Would you like us to call you within 3 days of delivering your quote?
 Yes No

If YES, when you like us to contact you?
 Phone between 8:30 - 4:30 M-F Phone between 9 - Noon Saturday