Manchester, Vermont Insurance Agency - Briggs Fowler Auto and Home Insurance

REQUEST A HOMEOWNERS QUOTE

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Name
Current Address

City
State
Zip
Property Location
Phone
Fax
Email
Social Security #
Birthdate

Current Carrier
Date Policy Expires

How long have you owned this home?

If this is a new purchase, please provide name of realtor.

Have you ever filed bankruptcy? Yes No

Has any insurance been cancelled or declined in the last 3 years? Yes No

Any claims or loss in the last 5 years ? Yes No

If yes, explain:

Year Built

Square Footage

Closing Date

Style

# Stories

# Families

Type of central heat

Years of updates:
Plumbing
Heating
Roof
Electrical

Are you a Smoker? Yes No

Is this a second home? Yes No

Will it be rented? Yes No

Is there a caretaker? Yes No

Smoke Detectors? Yes No

Central Alarm? Yes No

Pool? Yes No

Diving board? Yes No

Trampoline? Yes No

Fenced? Yes No

Wood or coal stove? Yes No

Underground oil tank? Yes No

Miles to fire station?

# feet to fire hydrant?

Dog #1:

Breed

Age

How long have you had this dog?

Claims History? Yes No

Dog #2:

Breed

Age

How long have you had this dog?

Claims History? Yes No

Dog #3:

Breed

Age

How long have you had this dog?

Claims History? Yes No

How much coverage for:
Dwelling
Loss of use
Other structures
Medical pay
Contents
Deductible
Liability

Optional coverage:
List any scheduled items, ie: jewelry, furs, antiques, etc

List any recreation vehicles

Additional Comments:

How did you hear about us?

How would you prefer to be contacted?

Security Code:
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Info@BriggsFowler.com
PO Box 1065 · 5293 Main Street · Manchester Center, VT 05255
TEL: 802-362-1225 · FAX: 802-362-0077