PERSONAL INFORMATION

Name*

E-Mail*

Address

City

State

Zip

Home Phone:

Work
Phone

Fax

Best Time to Contact

RESIDENCE INFORMATION

Type of Policy

Homeowners Condo Renters   

Is this a primary or secondary residence:

Primary Secondary   

Approximate year of construction:

Construction type:

Frame Aluminum Siding Brick Veneer Masonry   

Any losses in the last 3 years:

Yes No   

Number of families:

Single Two Family/Duplex Multi-Family   

COVERAGE INFORMATION

*Amount of current insurance on dwelling:

Personal property amount
(condo and renters only):

*Personal Liability (each occurrence):

$100,000 $200,000 $300,000 $400,000 $500,000 $1,000,000   

*Deductible:

$250 $500 $1000 $2500   

ENDORSEMENTS

Replacement cost options. (Please check all that apply):
Dwelling                              Contents:

Protective devices (Please check all that apply):

  Smoke Detectors

  Dead Bolt Locks

  Fire Extinguisher

  Non-smoker

  Central Station
Direct Alarm

  Central Station Fire Alarm

  Police Station Direct Alarm

  Fire Station Direct Alarm

  Automatic Sprinklers

OPTIONAL COVERAGES

Earthquake Coverage:

No Yes   

Flood Coverage:

No Yes   

Scheduled Property
(enter an amount for all that apply):

Jewelry

$

Fine Arts

$

Golf Equipment

$

Cameras

$

Musical Instruments

$

Silverware

$

Furs

$

Guns

$

5264 Washington Street West Roxbury, MA 02132 (617)325-5555 fax (617)323-5199

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