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Your Personal Data
Name (required):
Property Address:
City
State:
Zip Code:
E-mail Address (required):
Phone Number:
Fax Number:
Dwelling Information
Year Home Built:
Home Square Footage:
Is this Builder's Risk:
 Yes  No
Date of Home Completion MM/YY:
# of Units:
 Foundation Type:
Roof Type: # of Stories:
Do you own animals or pets?
 Yes No
If Yes to previous, please list type/breed:
Are you near brush area? Yes No
# of feet to nearest fire hydrant:
# of miles to nearest fire station:
Currently Insured? Yes No
Name of carrier, and how long insured:
Prior Claims? Yes No
Describe Claims in Detail:
Plumbing Type?
Electric Type?
# Bedrooms: # Bathrooms:
# Fireplaces: # Chimneys:
Special Features (Deck, A/C, Alarm, Pool, etc.):
Coverages
Dwelling: $ Contents: $
Liability: $ Deductible: $
Comments/Remarks:
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The Reinard Insurance Agency, Inc.
349 Bustleton Pike
Feasterville, PA 19053 (Directions)
Ph: 215-357-8600
Fx: 215-357-8061