Condominium Quote

North Carolina Residents Only!

Contact Information...
Name (required)
Address
Address (second line)
City		State	Zip

Please Contact Me Via...	Phone E-Mail Fax
Work Phone		Best Time To Call
Home Phone		Best Time To Call
Fax
E-Mail (required)

Current Insurance Information...
Current Insurance Company (not agency)
Date Current Policy Expires	mm/dd/yyyy

Property Information (if different from above)...
Address
Address (second line)
City				State	Zip

Residence Usage	Primary Secondary
Type of Construction
Year of Construction
Protection Devices Installed		Smoke Detectors	Dead Bolts
		Fire Extinguisher	Central Burglar / Fire Alarm
Property Within City Limits	Yes No
If NO -	Located within the fire district.
Distance in road miles to nearest fire department
Distance to nearest fire hydrant					ft.

Coverage Information ...
Value of Your Personal Property
Value of Unit (if greater than $1,000)
Loss Assessment Coverage ($1,000 improvement coverage included with basic policy)
Liability Coverage Limit
Deductible

High Value Items
(Item, Value)

These are high value items that need to be specifically identified, including jewelry, silverware, collectibles, furs, etc. Please list each item and its value.

This is a Request For Quotation Only.
No coverage is in effect until bound by an insurance carrier.

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Thank You!

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