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R. TAYLOR INSURANCE
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Name
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First
Last
Phone Number
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Marital Status
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Single
Married
Domestic Partner
Separated
Widowed
Divorced
Email
*
Gender
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Male
Female
Date of Birth
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Mailing Address
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Line 1
Line 2
City
State
Zip Code
Country
Property Address (if different from mailing address)
*
Line 1
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City
State
Zip Code
Country
New Purchase?
*
Yes
No
Current Insurance Carrier
*
Closing Date
*
Desired Personal Liability Limit
*
$300,000
$500,000
$1,000,000
Type of Siding
*
Vinyl
Aluminum
Wood
Brick
Type of Heat
*
Natural Gas
Electric
Propane
Other
Foundation
*
Slab
Crawl Space
Unfinished Basement
Finished Basement
Pool
*
Yes- Below ground
Yes- Above ground
No
Fireplace
*
Yes
No
Wood Burner
*
Yes- Inside
Yes- Outside
No
Pond
*
Yes
No
Trampoline
*
Yes
No
Occupied by
*
Owner
Tenant
Vacant
Zipline
*
Yes
No
Farming Acreage
*
Yes
No
Business conducted on premise
*
Yes
No
Year of roof update
*
Type of Farming Operation
*
Do you rent land/equipment to or from others?
*
Do you own a dog? If yes, what is the breed?
*
Additional Scheduled Items
*
Other Structures on Property
*
Detached garages, sheds, barns, utility buildings, animal enclosures, etc
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Home
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