Vermont Independent Insurance Company Hull Maynard Hersey

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.

Please provide your occupation.

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:

Would you like an umbrella quote? Yes No

Do you need a flood quote? Yes No

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

Sump Pump? Yes No

Pool? Yes No

Diving board? Yes No

Hot Tub? Yes No

Trampoline? Yes No

Fenced? Yes No

Wood or coal stove? Yes No

Do you have an outdoor wood boiler? Yes No

Underground oil tank? Yes No

Is any business conducted on your premise? Yes No

Any knob & tube wiring? 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:
Enter Code Here:

Info@HMHVT.com
105 Center Street
Rutland, VT 05701
800- 698- 3002
802- 773- 3000
Fax: 802- 775- 2110

Info@HMHVT.com
540 West Woodstock Road
Woodstock, VT 05091
800-457-4491
802-457-4143
Fax: 802-457-4169