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Secure Home Insurance Quote Request Form
Your Name
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First
Last
Email Address
(Required)
Phone Number
(Required)
Property Zip Code
(Required)
Insured Property Information
Property Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
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Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
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Brazil
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Bulgaria
Burkina Faso
Burundi
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Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Ã…land Islands
Country
Year Built
Date of Purchase
Month
Day
Year
Purchase Price
Market Value
Replacement Cost
Square Footage
Number of Stories
Select
1
1.5
2
2.5
3
3.5
4
Bi-Level
Tri-Level
Total Acreage
Is Property Within City Limits?
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Yes
No
Year Roof Last Updated
Distance to Fire Hydrant (feet)
Select
1-500 Feet
501-600
601-1000
1001 or Greater
1501 or Greater
None in Area
Don't Know
Dwelling Use
Select
Primary, (non-seasonal)
Secondary, (non-seasonal)
Seasonal, (secondary)
Farm
Vacant Occasionally Occupied
Other
Occupancy Type
Select
Owner Occupied
Tenant
Owner and Tenant
Unoccupied
Vacant
Course of Construction
Otherwise Occupied
Other
How Many Families Live in the Home
Select
One Family
Two Family
Three Family
Four Family
Construction Type
Select
Barn Plank
Brick
Brick on Block
Brick on Block, Custom
Brick Veneer
Frame
Logs
Poured Concrete
Siding, Aluminum
Siding, Hardboard
Siding, Plywood
Siding, Steel
Siding, T-111
Siding, Vinyl
Siding, Wood
Solid Stone
Stone on Block
Stone on Block, Custom Stone
Vinyl
Window Wall
Other
Don't Know
Siding Type
Select
None
Aluminum
Board
Face Brick
Brick Veneer
Cedar, Wood Shingle
Cement Fiber
Clapboard
Exterior Insulation and Finishing System on Studs (EIFSS)
Plastic/Vinyl Siding
Log Siding
Steel Siding
Stucco
Stone Veneer
Victorian Scalloped Shakes
Wood Siding
Wood Shakes
Other
Don't Know
Drywall or Plaster:
Select
Drywall
Plaster
Roof Type
Select
Aluminum Shingles
Architectural Shingles
Asbestos
Asphalt Shingle
Composition (Fiberglass, Asphalt, etc.)
Concrete (Not Tile)
Copper
Fiberglass
Faom
Gravel
METAL
Mineral Fiber
Plastic
Plywood
Rock
Rolled Roofing
Rubber Roof
Slate
Tar and Gravel
Tile
Tin
Wood Fiber Shingles
Wood Shakes
Wood Shingles
Wood Shake/Shingle
Other
Don't Know
Year Roof Last Updated
Year Plumbing Last Updated
Year Electric Last Updated
Year Heating Last Updated:
Primary Heat Source
Select
Electric
Natural Gas
Oil
Propane
Kerosene
Coal
Wood
Solar
None
Other
Don't Know
Primary Heat Unit Type
Select
Heat Pump
Hot Water Central (Boiler)
Radiant Floor
Forced Air Furnace
Fireplace
Wood Stove, Airtight
Wood Stove, Not Airtight
Number of Fireplaces
Select
0
1
2
3
4
5
6
Secondary Heat Source (Non Fireplace)
None
Electric
Natural Gas
Oil
Propane
Kerosene
Coal
Wood
Solar
Other
Don't Know
Secondary Heat Unit Type (Non Fireplace)
None
Heat Pump
Hot Water Central (Boiler)
Radiant Floor
Forced Air Furnace
Wood Stove, Airtight
Wood Stove, Not Airtight
Electric Circut Breaker
Select
Yes
No
Do you have any pets?
Select
Yes
No
Do you own any dogs of these breeds (Rottweiler, German Shepard, Doberman, Pitbull, Chow, Wolf Hybrid or mix of these)?
Select
Yes
No
Do you own livestock?
Select
Yes
No
Full Time Domestic Employees
No
1
2
3
4
5
6
7
8
9
10
More Than 10
Do you conduct any type of business on this property?
No
Accounting
Adult Care
Animal Related
Attorney
Auto/Vehicle Repair
Bookkeeping
Child Care
Clerical
Consultant
Contractor/Artisan
Daycare
Electronic/Machine Repair
Farming/Ranching
Financial Planner
Food Service
Hair Stylist/Beautician
Insurance Agent
Landscaper
Massage Therapist
Photographer
Medical related
Nail Salon
Real Estate Agent/Appraiser
Sales w/Demo
Sales No Demo
Tax Preparer
Teacher - Athletic
Teacher - Other
Veterinarian
Other
First Mortgage
Select
Yes
No
Second Mortgage
Select
Yes
No
Co-Signer
Select
Yes
No
Swimming Pool
Select
Yes
No
Pool Slide:
Select
Yes
No
Pool Diving Board
Select
Yes
No
Trampoline
Select
Yes
No
Smoke Detectors
Select
Yes
No
Fire Extinguisher
Select
Yes
No
Indoor Fire Sprinkler
Select
Yes
No
Burglar Alarm
Select
No
Yes, Central Monitored
Yes, Not Monitored
Deadbolt
Select
Yes
No
Gated Community
Select
Yes
No
Applicant Information
Your Name
First
Last
Date of Birth:
Month
Day
Year
Gender
Select
Male
Female
Occupation
Education
Select
Some High School
High School Graduate
GED
Vocational/Technical
Some College
Associate Degree
Bachelors Degree
Masters Degree
Doctorate
Medical School
Law School
Social Security #
License Number
Credit Report Consent
Select
Yes
No
Non Smoker
Select
Yes
No
Marital Status
Select
Single
Married
Divorced
Separated
Widowed
Domestic Partner
Civil Union Registered
Other
Spouse Full Name
Select
Single
Married
Divorced
Separated
Widowed
Domestic Partner
Civil Union Registered
Other
Spouse Date of Birth:
Month
Day
Year
Spouse Social Security #:
Spouse License Number:
Spouse Occupation:
Email
Home Phone
Work Phone
Mailing Address
City
Address
Mailing Address
City
State / Province / Region
ZIP / Postal Code
Years at Current Residence
Coverage Information
Policy Type
Select
Homeowners
Condo
Medical Payments
Select
1000
2000
3000
4000
5000
Dwelling Amount
Select
25000
50000
100
200
250
500
750
1000
2000
2500
3000
4000
5000
Dwelling Deductible
Select
.5%
1%
100000
200000
300000
400000
500000
Personal Liability Coverage
Select
25000
50000
100000
200000
300000
400000
500000
Personal Property Coverage
Select
1000
2500
5000
10000
20000
30000
40000
50000
100000
200000
300000
400000
500000
Wind/Hurricane Deductible
Select
1%
2%
3%
4%
5%
100
250
500
1000
New Policy Start
Month
Day
Year
New Policy Term
Select
6 month
12 month
Prior Policy Expiration
Month
Day
Year
Prior/Current Policy Carrier
Select
Other Standard
Other Non-Standard
No Prior Insurance
21st Century
AAA
Acuity
Adirondack Ins Exchange
AIG
Alfa Alliance
Allianz of America
Allianz of America-Jefferson
Allied
Allmerica
Allstate
America First
American Commerce
Amica
ASI Lloyds
Atlas General Agency
Austin Mutual
Auto-Owners
Badger Mutual
Balboa
Beacon National
Bunker Hill
Capital Insurance Group
Central Mutual of OH
Chubb
Cincinnati
Citizens
Colorado Casualty
CSE
Cumberland
Cypress
Dairyland
Donegal
Electric
EMC
Encompass
Erie
Esurance
Excelsior Insurance Company
Fair Plan
Farm Bureau
Farmers
Fidelity
Firemans Fund
First American
General Casualty
Germantown Mutual
GMAC
Grange
Grinnell
Guide One
Hanover
Harleysville
Hartford
Hartford OMNI
Hawkeye Security
Homeowners of America
Horace Mann
Houston General
Indiana
Indiana Farmers
Integrity
Kemper
Liberty Mutual
Liberty Northwest
Lloyds
Main Street America
Merchants Group
Mercury
Mercury
Midwestern Indemnity
Montgomery
MSA
Mutual Benefit
Nationwide
Nationwide-Scottsdale
Nationwide-Scottsdale
NJ Skylands
Northstar
Ohio Casualty
One Beacon
Oregon Mutual
Peerless/Montgomery
Pekin
Penn National
Plymouth Rock
Preferred Mutual
Prudential
Republic
Royal and Sun Alliance
Safeco
SECURA
Southern Mutual
Southern Trust
St. Paul/Travelers
Standard Mutual
State Auto
State Farm
Tower
Travelers
TWFG
Unigard
United Fire and Casualty
Unitrin
Universal
USAA
Utica National
West Bend
Western National
Western Reserve Group
Westfield
White Mountains
Wilson Mutual
Zurich
In the Last 5 Years Has Property Insurance Been Cancelled, Declined, or Non-Renewed
Select
Yes
No
Losses
Number of Losses Claimed on this Property:
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Loss Number 1
Type of Loss:
Select
CONTAMINATION
CREDIT CARD
DAMAGE TO PROPERTY OF OTHERS
DOG BITE (LIABILITY)
EARTH MOVEMENT
EARTHQUAKE
EXTENDED COVERAGE PERILS
FIRE
FLOOD
FREEZING WATER (INCLUDING BURST PIPES)
HAIL
LIABILITY (ALL OTHER)
LIGHTNING
MEDICAL PAYMENTS
MYSTERIOUS DISAPPEARANCE
MYSTERIOUS DISAPPEARANCE - SCHEDULED PROPERTY
PHYSICAL DAMAGE (ALL OTHER)
SLIP/FALL (LIABILITY)
SMOKE
THEFT SCHEDULED PROPERTY
THEFT/BURGLARY
VANDALISM/MALICIOUS MISCHIEF
WATER DAMAGE
WATERCRAFT
WIND
WORKER'S COMPENSATION
ALL OTHER
Date of Loss:
Month
Day
Year
Amount of Loss:
Loss Number 2
Type of Loss:
Select
CONTAMINATION
CREDIT CARD
DAMAGE TO PROPERTY OF OTHERS
DOG BITE (LIABILITY)
EARTH MOVEMENT
EARTHQUAKE
EXTENDED COVERAGE PERILS
FIRE
FLOOD
FREEZING WATER (INCLUDING BURST PIPES)
HAIL
LIABILITY (ALL OTHER)
LIGHTNING
MEDICAL PAYMENTS
MYSTERIOUS DISAPPEARANCE
MYSTERIOUS DISAPPEARANCE - SCHEDULED PROPERTY
PHYSICAL DAMAGE (ALL OTHER)
SLIP/FALL (LIABILITY)
SMOKE
THEFT SCHEDULED PROPERTY
THEFT/BURGLARY
VANDALISM/MALICIOUS MISCHIEF
WATER DAMAGE
WATERCRAFT
WIND
WORKER'S COMPENSATION
ALL OTHER
Date of Loss:
Month
Day
Year
Amount of Loss:
Loss Number 3
Type of Loss:
Select
CONTAMINATION
CREDIT CARD
DAMAGE TO PROPERTY OF OTHERS
DOG BITE (LIABILITY)
EARTH MOVEMENT
EARTHQUAKE
EXTENDED COVERAGE PERILS
FIRE
FLOOD
FREEZING WATER (INCLUDING BURST PIPES)
HAIL
LIABILITY (ALL OTHER)
LIGHTNING
MEDICAL PAYMENTS
MYSTERIOUS DISAPPEARANCE
MYSTERIOUS DISAPPEARANCE - SCHEDULED PROPERTY
PHYSICAL DAMAGE (ALL OTHER)
SLIP/FALL (LIABILITY)
SMOKE
THEFT SCHEDULED PROPERTY
THEFT/BURGLARY
VANDALISM/MALICIOUS MISCHIEF
WATER DAMAGE
WATERCRAFT
WIND
WORKER'S COMPENSATION
ALL OTHER
Date of Loss:
Month
Day
Year
Amount of Loss:
Loss Number 4
Type of Loss:
Select
CONTAMINATION
CREDIT CARD
DAMAGE TO PROPERTY OF OTHERS
DOG BITE (LIABILITY)
EARTH MOVEMENT
EARTHQUAKE
EXTENDED COVERAGE PERILS
FIRE
FLOOD
FREEZING WATER (INCLUDING BURST PIPES)
HAIL
LIABILITY (ALL OTHER)
LIGHTNING
MEDICAL PAYMENTS
MYSTERIOUS DISAPPEARANCE
MYSTERIOUS DISAPPEARANCE - SCHEDULED PROPERTY
PHYSICAL DAMAGE (ALL OTHER)
SLIP/FALL (LIABILITY)
SMOKE
THEFT SCHEDULED PROPERTY
THEFT/BURGLARY
VANDALISM/MALICIOUS MISCHIEF
WATER DAMAGE
WATERCRAFT
WIND
WORKER'S COMPENSATION
ALL OTHER
Date of Loss:
Month
Day
Year
Amount of Loss:
Loss Number 5
Type of Loss:
Select
CONTAMINATION
CREDIT CARD
DAMAGE TO PROPERTY OF OTHERS
DOG BITE (LIABILITY)
EARTH MOVEMENT
EARTHQUAKE
EXTENDED COVERAGE PERILS
FIRE
FLOOD
FREEZING WATER (INCLUDING BURST PIPES)
HAIL
LIABILITY (ALL OTHER)
LIGHTNING
MEDICAL PAYMENTS
MYSTERIOUS DISAPPEARANCE
MYSTERIOUS DISAPPEARANCE - SCHEDULED PROPERTY
PHYSICAL DAMAGE (ALL OTHER)
SLIP/FALL (LIABILITY)
SMOKE
THEFT SCHEDULED PROPERTY
THEFT/BURGLARY
VANDALISM/MALICIOUS MISCHIEF
WATER DAMAGE
WATERCRAFT
WIND
WORKER'S COMPENSATION
ALL OTHER
Date of Loss:
Month
Day
Year
Amount of Loss:
Loss Number 6
Type of Loss:
Select
CONTAMINATION
CREDIT CARD
DAMAGE TO PROPERTY OF OTHERS
DOG BITE (LIABILITY)
EARTH MOVEMENT
EARTHQUAKE
EXTENDED COVERAGE PERILS
FIRE
FLOOD
FREEZING WATER (INCLUDING BURST PIPES)
HAIL
LIABILITY (ALL OTHER)
LIGHTNING
MEDICAL PAYMENTS
MYSTERIOUS DISAPPEARANCE
MYSTERIOUS DISAPPEARANCE - SCHEDULED PROPERTY
PHYSICAL DAMAGE (ALL OTHER)
SLIP/FALL (LIABILITY)
SMOKE
THEFT SCHEDULED PROPERTY
THEFT/BURGLARY
VANDALISM/MALICIOUS MISCHIEF
WATER DAMAGE
WATERCRAFT
WIND
WORKER'S COMPENSATION
ALL OTHER
Date of Loss:
Month
Day
Year
Amount of Loss:
Loss Number 7
Type of Loss:
Select
CONTAMINATION
CREDIT CARD
DAMAGE TO PROPERTY OF OTHERS
DOG BITE (LIABILITY)
EARTH MOVEMENT
EARTHQUAKE
EXTENDED COVERAGE PERILS
FIRE
FLOOD
FREEZING WATER (INCLUDING BURST PIPES)
HAIL
LIABILITY (ALL OTHER)
LIGHTNING
MEDICAL PAYMENTS
MYSTERIOUS DISAPPEARANCE
MYSTERIOUS DISAPPEARANCE - SCHEDULED PROPERTY
PHYSICAL DAMAGE (ALL OTHER)
SLIP/FALL (LIABILITY)
SMOKE
THEFT SCHEDULED PROPERTY
THEFT/BURGLARY
VANDALISM/MALICIOUS MISCHIEF
WATER DAMAGE
WATERCRAFT
WIND
WORKER'S COMPENSATION
ALL OTHER
Date of Loss:
Month
Day
Year
Amount of Loss:
Loss Number 8
Type of Loss:
Select
CONTAMINATION
CREDIT CARD
DAMAGE TO PROPERTY OF OTHERS
DOG BITE (LIABILITY)
EARTH MOVEMENT
EARTHQUAKE
EXTENDED COVERAGE PERILS
FIRE
FLOOD
FREEZING WATER (INCLUDING BURST PIPES)
HAIL
LIABILITY (ALL OTHER)
LIGHTNING
MEDICAL PAYMENTS
MYSTERIOUS DISAPPEARANCE
MYSTERIOUS DISAPPEARANCE - SCHEDULED PROPERTY
PHYSICAL DAMAGE (ALL OTHER)
SLIP/FALL (LIABILITY)
SMOKE
THEFT SCHEDULED PROPERTY
THEFT/BURGLARY
VANDALISM/MALICIOUS MISCHIEF
WATER DAMAGE
WATERCRAFT
WIND
WORKER'S COMPENSATION
ALL OTHER
Date of Loss:
Month
Day
Year
Amount of Loss:
Loss Number 9
Type of Loss:
Select
CONTAMINATION
CREDIT CARD
DAMAGE TO PROPERTY OF OTHERS
DOG BITE (LIABILITY)
EARTH MOVEMENT
EARTHQUAKE
EXTENDED COVERAGE PERILS
FIRE
FLOOD
FREEZING WATER (INCLUDING BURST PIPES)
HAIL
LIABILITY (ALL OTHER)
LIGHTNING
MEDICAL PAYMENTS
MYSTERIOUS DISAPPEARANCE
MYSTERIOUS DISAPPEARANCE - SCHEDULED PROPERTY
PHYSICAL DAMAGE (ALL OTHER)
SLIP/FALL (LIABILITY)
SMOKE
THEFT SCHEDULED PROPERTY
THEFT/BURGLARY
VANDALISM/MALICIOUS MISCHIEF
WATER DAMAGE
WATERCRAFT
WIND
WORKER'S COMPENSATION
ALL OTHER
Date of Loss:
Month
Day
Year
Amount of Loss:
Loss Number 10
Type of Loss:
Select
CONTAMINATION
CREDIT CARD
DAMAGE TO PROPERTY OF OTHERS
DOG BITE (LIABILITY)
EARTH MOVEMENT
EARTHQUAKE
EXTENDED COVERAGE PERILS
FIRE
FLOOD
FREEZING WATER (INCLUDING BURST PIPES)
HAIL
LIABILITY (ALL OTHER)
LIGHTNING
MEDICAL PAYMENTS
MYSTERIOUS DISAPPEARANCE
MYSTERIOUS DISAPPEARANCE - SCHEDULED PROPERTY
PHYSICAL DAMAGE (ALL OTHER)
SLIP/FALL (LIABILITY)
SMOKE
THEFT SCHEDULED PROPERTY
THEFT/BURGLARY
VANDALISM/MALICIOUS MISCHIEF
WATER DAMAGE
WATERCRAFT
WIND
WORKER'S COMPENSATION
ALL OTHER
Date of Loss:
Month
Day
Year
Amount of Loss:
Loss Number 11
Type of Loss:
Select
CONTAMINATION
CREDIT CARD
DAMAGE TO PROPERTY OF OTHERS
DOG BITE (LIABILITY)
EARTH MOVEMENT
EARTHQUAKE
EXTENDED COVERAGE PERILS
FIRE
FLOOD
FREEZING WATER (INCLUDING BURST PIPES)
HAIL
LIABILITY (ALL OTHER)
LIGHTNING
MEDICAL PAYMENTS
MYSTERIOUS DISAPPEARANCE
MYSTERIOUS DISAPPEARANCE - SCHEDULED PROPERTY
PHYSICAL DAMAGE (ALL OTHER)
SLIP/FALL (LIABILITY)
SMOKE
THEFT SCHEDULED PROPERTY
THEFT/BURGLARY
VANDALISM/MALICIOUS MISCHIEF
WATER DAMAGE
WATERCRAFT
WIND
WORKER'S COMPENSATION
ALL OTHER
Date of Loss:
Month
Day
Year
Amount of Loss:
Loss Number 12
Type of Loss:
Select
CONTAMINATION
CREDIT CARD
DAMAGE TO PROPERTY OF OTHERS
DOG BITE (LIABILITY)
EARTH MOVEMENT
EARTHQUAKE
EXTENDED COVERAGE PERILS
FIRE
FLOOD
FREEZING WATER (INCLUDING BURST PIPES)
HAIL
LIABILITY (ALL OTHER)
LIGHTNING
MEDICAL PAYMENTS
MYSTERIOUS DISAPPEARANCE
MYSTERIOUS DISAPPEARANCE - SCHEDULED PROPERTY
PHYSICAL DAMAGE (ALL OTHER)
SLIP/FALL (LIABILITY)
SMOKE
THEFT SCHEDULED PROPERTY
THEFT/BURGLARY
VANDALISM/MALICIOUS MISCHIEF
WATER DAMAGE
WATERCRAFT
WIND
WORKER'S COMPENSATION
ALL OTHER
Date of Loss:
Month
Day
Year
Amount of Loss:
Loss Number 13
Type of Loss:
Select
CONTAMINATION
CREDIT CARD
DAMAGE TO PROPERTY OF OTHERS
DOG BITE (LIABILITY)
EARTH MOVEMENT
EARTHQUAKE
EXTENDED COVERAGE PERILS
FIRE
FLOOD
FREEZING WATER (INCLUDING BURST PIPES)
HAIL
LIABILITY (ALL OTHER)
LIGHTNING
MEDICAL PAYMENTS
MYSTERIOUS DISAPPEARANCE
MYSTERIOUS DISAPPEARANCE - SCHEDULED PROPERTY
PHYSICAL DAMAGE (ALL OTHER)
SLIP/FALL (LIABILITY)
SMOKE
THEFT SCHEDULED PROPERTY
THEFT/BURGLARY
VANDALISM/MALICIOUS MISCHIEF
WATER DAMAGE
WATERCRAFT
WIND
WORKER'S COMPENSATION
ALL OTHER
Date of Loss:
Month
Day
Year
Amount of Loss:
Loss Number 14
Type of Loss:
Select
CONTAMINATION
CREDIT CARD
DAMAGE TO PROPERTY OF OTHERS
DOG BITE (LIABILITY)
EARTH MOVEMENT
EARTHQUAKE
EXTENDED COVERAGE PERILS
FIRE
FLOOD
FREEZING WATER (INCLUDING BURST PIPES)
HAIL
LIABILITY (ALL OTHER)
LIGHTNING
MEDICAL PAYMENTS
MYSTERIOUS DISAPPEARANCE
MYSTERIOUS DISAPPEARANCE - SCHEDULED PROPERTY
PHYSICAL DAMAGE (ALL OTHER)
SLIP/FALL (LIABILITY)
SMOKE
THEFT SCHEDULED PROPERTY
THEFT/BURGLARY
VANDALISM/MALICIOUS MISCHIEF
WATER DAMAGE
WATERCRAFT
WIND
WORKER'S COMPENSATION
ALL OTHER
Date of Loss:
Month
Day
Year
Amount of Loss:
Loss Number 15
Type of Loss:
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CONTAMINATION
CREDIT CARD
DAMAGE TO PROPERTY OF OTHERS
DOG BITE (LIABILITY)
EARTH MOVEMENT
EARTHQUAKE
EXTENDED COVERAGE PERILS
FIRE
FLOOD
FREEZING WATER (INCLUDING BURST PIPES)
HAIL
LIABILITY (ALL OTHER)
LIGHTNING
MEDICAL PAYMENTS
MYSTERIOUS DISAPPEARANCE
MYSTERIOUS DISAPPEARANCE - SCHEDULED PROPERTY
PHYSICAL DAMAGE (ALL OTHER)
SLIP/FALL (LIABILITY)
SMOKE
THEFT SCHEDULED PROPERTY
THEFT/BURGLARY
VANDALISM/MALICIOUS MISCHIEF
WATER DAMAGE
WATERCRAFT
WIND
WORKER'S COMPENSATION
ALL OTHER
Date of Loss:
Month
Day
Year
Amount of Loss:
Loss Number 16
Type of Loss:
Select
CONTAMINATION
CREDIT CARD
DAMAGE TO PROPERTY OF OTHERS
DOG BITE (LIABILITY)
EARTH MOVEMENT
EARTHQUAKE
EXTENDED COVERAGE PERILS
FIRE
FLOOD
FREEZING WATER (INCLUDING BURST PIPES)
HAIL
LIABILITY (ALL OTHER)
LIGHTNING
MEDICAL PAYMENTS
MYSTERIOUS DISAPPEARANCE
MYSTERIOUS DISAPPEARANCE - SCHEDULED PROPERTY
PHYSICAL DAMAGE (ALL OTHER)
SLIP/FALL (LIABILITY)
SMOKE
THEFT SCHEDULED PROPERTY
THEFT/BURGLARY
VANDALISM/MALICIOUS MISCHIEF
WATER DAMAGE
WATERCRAFT
WIND
WORKER'S COMPENSATION
ALL OTHER
Date of Loss:
Month
Day
Year
Amount of Loss:
Loss Number 17
Type of Loss:
Select
CONTAMINATION
CREDIT CARD
DAMAGE TO PROPERTY OF OTHERS
DOG BITE (LIABILITY)
EARTH MOVEMENT
EARTHQUAKE
EXTENDED COVERAGE PERILS
FIRE
FLOOD
FREEZING WATER (INCLUDING BURST PIPES)
HAIL
LIABILITY (ALL OTHER)
LIGHTNING
MEDICAL PAYMENTS
MYSTERIOUS DISAPPEARANCE
MYSTERIOUS DISAPPEARANCE - SCHEDULED PROPERTY
PHYSICAL DAMAGE (ALL OTHER)
SLIP/FALL (LIABILITY)
SMOKE
THEFT SCHEDULED PROPERTY
THEFT/BURGLARY
VANDALISM/MALICIOUS MISCHIEF
WATER DAMAGE
WATERCRAFT
WIND
WORKER'S COMPENSATION
ALL OTHER
Date of Loss:
Month
Day
Year
Amount of Loss:
Loss Number 18
Type of Loss:
Select
CONTAMINATION
CREDIT CARD
DAMAGE TO PROPERTY OF OTHERS
DOG BITE (LIABILITY)
EARTH MOVEMENT
EARTHQUAKE
EXTENDED COVERAGE PERILS
FIRE
FLOOD
FREEZING WATER (INCLUDING BURST PIPES)
HAIL
LIABILITY (ALL OTHER)
LIGHTNING
MEDICAL PAYMENTS
MYSTERIOUS DISAPPEARANCE
MYSTERIOUS DISAPPEARANCE - SCHEDULED PROPERTY
PHYSICAL DAMAGE (ALL OTHER)
SLIP/FALL (LIABILITY)
SMOKE
THEFT SCHEDULED PROPERTY
THEFT/BURGLARY
VANDALISM/MALICIOUS MISCHIEF
WATER DAMAGE
WATERCRAFT
WIND
WORKER'S COMPENSATION
ALL OTHER
Date of Loss:
Month
Day
Year
Amount of Loss:
Loss Number 19
Type of Loss:
Select
CONTAMINATION
CREDIT CARD
DAMAGE TO PROPERTY OF OTHERS
DOG BITE (LIABILITY)
EARTH MOVEMENT
EARTHQUAKE
EXTENDED COVERAGE PERILS
FIRE
FLOOD
FREEZING WATER (INCLUDING BURST PIPES)
HAIL
LIABILITY (ALL OTHER)
LIGHTNING
MEDICAL PAYMENTS
MYSTERIOUS DISAPPEARANCE
MYSTERIOUS DISAPPEARANCE - SCHEDULED PROPERTY
PHYSICAL DAMAGE (ALL OTHER)
SLIP/FALL (LIABILITY)
SMOKE
THEFT SCHEDULED PROPERTY
THEFT/BURGLARY
VANDALISM/MALICIOUS MISCHIEF
WATER DAMAGE
WATERCRAFT
WIND
WORKER'S COMPENSATION
ALL OTHER
Date of Loss:
Month
Day
Year
Amount of Loss:
Loss Number 20
Type of Loss:
Select
CONTAMINATION
CREDIT CARD
DAMAGE TO PROPERTY OF OTHERS
DOG BITE (LIABILITY)
EARTH MOVEMENT
EARTHQUAKE
EXTENDED COVERAGE PERILS
FIRE
FLOOD
FREEZING WATER (INCLUDING BURST PIPES)
HAIL
LIABILITY (ALL OTHER)
LIGHTNING
MEDICAL PAYMENTS
MYSTERIOUS DISAPPEARANCE
MYSTERIOUS DISAPPEARANCE - SCHEDULED PROPERTY
PHYSICAL DAMAGE (ALL OTHER)
SLIP/FALL (LIABILITY)
SMOKE
THEFT SCHEDULED PROPERTY
THEFT/BURGLARY
VANDALISM/MALICIOUS MISCHIEF
WATER DAMAGE
WATERCRAFT
WIND
WORKER'S COMPENSATION
ALL OTHER
Date of Loss:
Month
Day
Year
Amount of Loss:
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Avid Insurance Services
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