Homeowners Insurance | Home Insurance policy by Wiglesworth Rindom

QUICK QUOTE FORMS:

Home | Auto | Flood

Call: (561) 637-2424

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PERSONAL INFORMATION

First Name:

Last Name:

E-mail address:

Daytime Phone Number:

Evening Phone Number:

Fax Number:

Address:

City:

State:

Zip code:

Date of birth:

STRUCTURAL INFORMATION

How many stories is your home?

What is the total square footage of the living area of your home?

Do you have a Screen Enclosure that extends beyond the roof line of the home?

Yes No

Closing Date if new Purchase:

WHAT IS THE STRUCTURE OF THE FOLLOWING

Roof:

Age Of Roof:

Exterior of your home:

Garage:

What is the replacement cost of your home:

IS YOUR HOME LOCATED

Within 1000 feet of a fire hydrant?

Yes No

Within 5 miles of the fire station?

Yes No

GENERAL QUESTIONS

Year home built:

What part of the year is the home occupied?

What term best describes your kitchen?

Did you experience any loss or claims in the last 5 years? If yes please list details in remarks.

Yes No

Do you own a Dog?

Yes No

Current Insurance Company Name

PROTECTIVE DEVICES

Fire alarm?

Burglar alarm:

Engineered Hurricane Shutters?

Yes No

Gated community:

Yes No

24 Hour Guards at the Gate:

Yes No

Do the Guards Patrol the Community:

Yes No

HOMEOWNERS COVERAGES AND DEDUCTIBLES

Dwelling (Coverage A - Replacement cost of your home):

Desired deductible:

REMARKS

How Did You Hear Of Us?:

Specializing in Home Insurance, Auto Insurance and Flood Insurance.

4 SE 6TH Ave., Delray Beach, FL 33483
Phone: (561) 637-2424 Fax: (561) 637-2226
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