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General Information
Bold = Required field
First Name
M.I.
Last Name
Address
City
State
Zip Code
E-mail Address
Phone
Date of Birth
Current Policy Information
Current Insurance Carrier (Not Agency)
Policy Expiration Date
Amount Insured For
Deductible
Home Information
How long at present address?
Previous address (if less that 2 years)
Numbers of claims in the last 3 years
Year home was built
Square footage of home (excluding basement and garage)
Structure Information
Type
Construction
Age of roof
Foundation
Garage
Additional Features
Bathrooms # of full
Bathrooms # of half
Basement
Sq. Ft.
Deck Sq. Ft.
Porch Sq. Ft.
Patio Sq. Ft.
Number of Fireplaces
Number of Chimneys
Number of Hearths
Electrical System
Amps
Heating System
Woodstove
Trampoline
Pool
If yes,
Slide / Diving Board
Height of fence
Dog
If yes, what breed?
More Information
Any bankruptcy in the last 5 years?
Any losses in the last 5 years?
If yes, please explain:
Please give any additional comments about the coverage you desire:
Are you a current or previous customer of Yes Insurance Agency or Joel Ciotta?
Yes
No
How did you hear of Yes Insurance?