We would appreciate it if you would take a few moments to answer the following questions. Please be assured that we do not share or sell personal information about you except when we have your permission.
First Name
Last Name
Property Address
City
State
Zip Code
E-mail Address
Phone #
BUILDING INFORMATION
Year Built:
Number of Families:
1- Family
2- Family
3- Family
RATING INFORMATION
Do you have auto insurance in MA?
Yes No
If yes, with what company?
Do You own any pets?
Yes No
If yes, please indicate type(s) and breed(s)
Are there any smokers in the house?
Yes No
Do you own a trampoline?
Yes No
INSURANCE HISTORY
Within the past three years, have you had any home insurance claims? Yes No
If yes, please indicate the type(s) of losses, and amount paid by the insurance company:
Have you had an insurance policy declined, cancelled, or non-renewed in the past three years?Yes No
If yes, please explain:
If you are already insured with us please let us know who your agent is so we can direct your submission accordingly?