# Bedrooms:		# Bathrooms:
# Fireplaces:		# Chimneys:
If home is over 25 years old, what year(s) were the following updated? (1) Wiring, 2) Heating, 3) Plumbing, 4) Roof 3)
Any business on premises? (If Yes, list in remarks)		No Yes
Special features (i.e., deck, air conditioning, alarm systems, pool, etc.)
Coverages:
Dwelling Cov. $		Contents $
Liability Cov. $		Deductible $ ($250, $500, $1,000, etc.)
Comments/Remarks (describe any scheduled jewelry, in-home business, oil tank location, or other special coverages/remarks here):
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