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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:

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
Pool?   Yes   No
Diving board?   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?



Get a Quote Companies Represented Insurance Programs   Our Staff     Links     Home  
Info@HMHVT.com
105 Center Street
Rutland, VT 05701
800- 698- 3002
802- 773- 3000

Fax: 802- 775- 2110
Info@HMHVT.com
Shaftsbury, VT
800-698-3002
802-683-7116
Info@HMHVT.com
540 West Woodstock Road
Woodstock, VT 05091
800-457-4491
802-457-4143

Fax: 802-457-4169

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