THE HLAVIN AGENCY

Insurance Type: *
select Vehicle Insurance Home Insurance Vehicle and Home Insurance Business Insurance Life Insurance Medicare Suppliment Long Term Care Insurance Other

First Name: *


Last Name: *


Email: *


Phone:


Address:


City:


state:


Zip:


Marital Status:


Date of Birth:


DL #:


SS #:


Education:


Occupation:


Employer:

Vehicles

Current Carrier:


Exp Date:


Years with carrier:


Vehicle #1 (Make, Model,Yr):


Vehicle #1 VIN:


Vehicle #1 Odometer:


Vehicle #1 Distance to work:


Vehicle #1 Primary Driver Name:


Vehicle #2 (Make, Model,Yr):


Vehicle #2 VIN:


Vehicle #2 Odometer:


Vehicle #2 Distance to work:


Vehicle #2 Primary Driver Name:


Any Claims in the last five years::

Home

Current Carrier:


Exp Date:


Years with Carrier:

Smoking in House:
select Yes No

In Home Business?:
select Yes No

Any Drones?:
select Yes No

Smoke Detectors?:
select Yes No

Deadbolts?:
select Yes No

Fire Extinguisher?:
select Yes No

Neighbors in View?:
select Yes No

Gated?:
select Yes No

Inside City Limits?:
select Yes No

How many living in the dwelling to be insured?:


Feet to Fire Hydrant:


Distance to Fire Station:


Construction Type:


Stories:


Style:


Roofing Material:


Age of Roof:


Year Built:


Purchase Date:


Garage:


Bedrooms:


Baths:


Living Area (excluding basement listed below):
sq ft

Finished Basement:
sq ft

Heating and Cooling:


Furnace Age:

Fireplace Type:
select No Fireplace Wood burning Gas

Wood Stove:
select Yes No

Circuit Breakerse:
select Yes No

Plumbing (well, city, septic):


Deck ft x ft (covered/not covered):


Any Claims in the last five years::


Questions/Comments:



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