Wind

WIND/HAIL ONLINE QUOTE

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Agent Information

Agency Name

-OR-

Agent Lookup Code

Agent Names

Agent Name (first and last)

Phone:

Fax:

Agent Email:

Agency's Mailing Address

Agency City

Agency State

Agency Zip

Insured Information

Insured Name:

Insured Email:

Insured's Mailing Address

Insured's Mailing City

Insured's Mailing State

Insured Zip

Location #1

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Property Address:

Property City:

Property State:*

Property Zip:

Interest in Property:

Value of Property:

Contents Limit:

Business Interruption Limit:

Construction:

Is Building Residential? (Click if Yes)

Type of Occupancy

Distance to the Coast:

Last Roof Update: (YYYY)

Protection Class:

Number of Stories:

Area of Property: (SqFt)

Any Prior Losses?

Year Built:

Commission

What commission would you like for this account?

Additional Comments

Any Additional Comments

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For higher limits or coverage options not listed, please contact Barry Scott, Ext 108.

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