John Fleming Insurance Agency
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Instructions: Please fill out the information below. Areas with an asterisk (*) need to be filled in.
Contact Information
Name*
Address
City
Postal Code
Email Address*
Telephone:*
Fax:
   
Detailed Quote Information
1. Building Limit
2. Deductibe Required
3. Limit of liablity coverage required
4. Type of Structure
5. Construction of Building
6. Year Building Constructed
7. Any Portion of Home Used As Rental
8. Type of Heating
9. Wood Heat
10. Fire Protection
11. Mature Age Discount Applies
If Yes, please provide date of birth
12. Alarm System
If Yes,
13. Mortgage Free Discount Applies
14. Years Continuously Insured Claimsfree
15. Additional Coverage Required
If Yes, please provide details:
16. Have you had any losses in the last 3 years?
If Yes, give details & claims amount paid by the insurance company:
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