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    PO Box 244571
    Boynton Beach, FL 33424-4571
    Phone: 561-736-2162
    Fax: 561-736-0228

    E-Mail us at:

    For Your Convenience,
    We gladly accept:

    "All Our Policies Come With
    an Agent!"

    Need Coverage TODAY? After Submitting
    Your Quote Form (see below), Call Toll-Free:
    (Monday-Friday 9:00am-5:00pm Florida local time)

    Homeowners Insurance
    Quotation Form
    One Simple Form - takes only 2-3 Minutes!

    Your Personal Data:
    Your Name:
    Property Address:
    Your "County" is?
    State: MUST be Florida!
    E-Mail (REQUIRED):
    Fax (optional):

    Dwelling Information
    Year Home Built:
    Home Square footage:
    Is this Builder's Risk?
    (new home constr.)
    NO YES
    Month/Year home
    to be complete:
    Frame or Masonry Construction? Frame Masonry
    Number of units: 1 family Duplex
    Type foundation: Slab Crawlspace over slab
    Pier & Post Other (list in remarks)
    Type Roof: Shingle Wood Shake
    Tar/Gravel Spanish Tile
    Metal Other
    Number of stories: One 1.5
    Two Three
    Do you own animals or pets? Yes No
    If yes, list type/for dogs, list 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 & how long insured?
    Prior Claims? Yes No
    Describe claims in detail:
    Rate Your Credit History and Past Insurance Payment History:
    (Some companies products are
    based on your credit and payment history.)
    Excellent Fair
    Poor Horrible
    Plumbing type: Copper Galvanized
    Mixed (Copper/Galvanized)
    Circuit Breakers or fuses? Breakers Fuses

    # Bedrooms: # Bathrooms:
    # Fireplaces: # Chimneys:
    Special features
    (i.e., deck, air conditioning, alarm systems, pool, etc.)
    Dwelling Cov. $ Contents $
    Liability Cov. $ Deductible $
    ($250, $500, $1,000, etc.)
    (describe any scheduled jewelry, in-home business, or other special coverages needed here):
    Send my quotation via: E-Mail Fax
    Regular Mail
    Call Me By Phone

    Thank you for filling out this form COMPLETELY!

    We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

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